Licensed Clinical Social Worker

Social Worker

Interviews patient/patient's social support system if applicable to complete initiate psychosocial evaluation/assessment. Provides counseling/support/education to patient/patient's social support system. Assists patients/patient's social support system in healthy coping strategies and improving overall well-being. Works collaboratively with the patients and primary care provider to establish and implement a plan of care that meets the patient's identified psychosocial needs. Works with each primary care provider to enhance the health of the patient referred, documents patient visits per standard as well as appointment attendance and follow up. Works to close appropriate care gaps to advance wellness. Serves as a resource to SPN regarding emotional, social, and psychosocial components of the patient's illness and its effects. Assists and facilitates a care team approach with Primary Care referring provider in understanding and integrating aspects into the plan of care. Intervenes in crisis situations, appropriately and effectively applying crisis intervention and skills. Works with the SPN team to assess and evaluate the patient/patient's social support system for the appropriate level of care or environment setting to meet care needs. Participates in care planning meetings as requested. Maintains current knowledge and researches availability of community agencies and community resources for social, emotional or financial assistance. Rounds with each provider daily in clinic to build referral relationships and professional "warm" patient handoffs, ensure clinic manager and providers are aware of availability daily and hours on site for acute intervention if needed. Provides information, education to patients and their social support on community resources and options appropriate to the age of the patients served, in collaboration with the Clinical Care Team. Make referrals to community agencies as needed. Reports suspected cases of child & adult abuse/neglect/exploitation. Serves as liaison between practice, patients/patient's social support system and Department of Social Services during evaluation/investigation. Identifies and records clinical, psychosocial and financial barriers to a smooth transition across the healthcare continuum and assists in identifying and facilitating system improvements. Works with SPN leadership to identify problems, recommended solutions and works toward resolution. Develops and maintains accurate clinical records in EPIC of each referred patient. Documents in EPIC according to departmental standards. Works collaboratively with SPN leadership to build LCSW integrated primary care program.