Complex Care Team Clinical Social Worker Lead (LICSW)

The Complex Care Team Clinical Social Worker is an integral member of the Complex Care Management Team. They are a vital collaborator on the care team to help reduce length of stay and readmission due to psychosocial factors. In conjunction with the unit-based teams they support and interface with the interdisciplinary health care teams. The Complex Care Team Clinical Social Worker provides and oversees the provision of psychosocial care for patients who have co-morbidities that drive evaluation, intervention and planning for patients with complex psychosocial risk (e.g., safety concerns, protective services, homelessness, etc.) They provide clinical services to patients/families that address psychosocial, environmental, age specific and cultural issues to maximize emotional, social and physical wellbeing and the effective use of health care and community resources, to ensure appropriate and high-quality services are provided after discharge at the right site of care, all while supporting clinical excellence for discharge plans. This is accomplished by conducting rapid clinical biopsychosocial assessments, providing intervention and treatment as indicated and in collaboration with any involved social worker on the care team; identifying high risk psychosocial factors that impact health status and helping care teams understand the influence of those factors on the course of medical care.
The Complex Care Team Clinical Social Worker collaborates with and provides social work consultation to other disciplines within the Hospital and community and participates in Departmental, Hospital, and community task forces and committees.
The Complex Care Team Clinical Social Worker reports directly to the Senior Nurse Director of Case Management with clinical peer support from the Director of Social Work.
Clinical Practice:
Rapidly performs clinical biopsychosocial assessments to include evaluation of social history, current functioning, mental health, substance use, psychiatric history, support system, coping styles, understanding of illness, barriers to care, cultural issues, abuse/neglect/safety concerns, intimate partner violence.
Provides psychosocial assessment of families to determine family relationships/systems as they relate to care of the patient. Identifies family decision makers and caregivers, family understanding of illness and trajectory of care and coping styles, family resources and cultural considerations.
Formulates diagnostic impressions, recommendations, and plan. Collaborates with care team to develop and optimize plan of care and disposition to reduce length of stay and readmission.
Works in a very fast-paced, dynamic, demanding environment, receiving consults throughout the day to evaluate a broad range of issues and concerns acutely. Manages consultation requests by understanding and prioritizing needs relative to patient acuity and barriers to safe discharge.
Consult reasons include but are not limited to: adjustment to new diagnosis/illness/injury, end of life and complex bereavement needs, safety concerns including child, disabled, elder abuse, neglect and financial exploitation, sexual assault, intimate partner violence, trauma, mental health and psychiatric concerns, complex relationship and family dynamics, coping, advanced directive/guardianship and custody concerns, limited supports and accessing resources.
Provides mandated assessments when abuse is suspected (child, disabled adult, elder) and specialized safety assessment when violence is suspected. Files mandated reports as indicated. Provides consultation and guidance to mandated reporters of other disciplines when they must file.
Employs a range of clinical interventions such as psychotherapy (individual, couples, families, and group), short-term counseling, crisis intervention, safety planning, care coordination, complementary therapies, information and referral. Advocates on behalf of patients and families to gain access to services and resources.
Works effectively as a vital collaborator with the interdisciplinary care team. Provides psychosocial consultation on patient/family care and management. Facilitates the appropriate and efficient use of Hospital resources.
Collaborates with many internal collaterals to include but not limited to: Office of Patient Relations, Office of General Counsel, Optimum Care, Child Protection Team, HAVEN, Police and Security, International Office, Office of Decedent Affairs and external collateral contacts and agencies to optimize the plan of care for patients and families.
Identifies patients' psychosocial, financial, legal, psychiatric or substance use discharge barriers that affect patient care progression and collaborates with the team to facilitate safe transitions in care.
Coordinates family team meeting as needed and when appropriate in collaboration with the interdisciplinary team.
Facilitates the appropriate and efficient use of hospital and community resources.
Performs other duties as assigned.
Teaching and Education:
Assesses patient/family learning needs, styles and readiness. Educates patients/families based on treatment plan, identifies barriers to care, diversity and equity issues and learning styles.
Provides education and consultation to interdisciplinary health care providers, social work staff, students and community on psychosocial issues for patients.
Presents cases at weekly Complex/Leadership meetings
Facilitates, leads, or participates in Departmental and Hospital committees as necessary.
Collaboration
Collaborates and consults with patient, families and providers within the Hospital and community to develop and implement patient care plans. Refers to and collaborates with Departmental programs, Hospital programs, outside agencies, facilities, payors, and other relevant community resources.
Organizational/Administrative Skills:
Takes responsibility for own administrative duties, including, timely and accurate reporting of time worked.
Completes timely clinical documentation including psychosocial assessment, post acute referrals and progress notes.
Participates in Departmental and Hospital committees. May chair committees as applicable.
Professional Conduct:
Adheres to the profession's clinical standards and Code of Ethics.
Adheres to the Department and Hospital standards, policies and procedures.
Promotes Departmental and Hospital public relations. Provides risk management.
Adheres to Departmental and Hospital quality/safety standards.
Professional Development:
Participates in individual clinical supervision as appropriate to professional development.
Is responsible for own professional development. Attends continuing education and professional activities related to job responsibilities and career goals. Keeps current with social work and health care developments pertinent to job and profession.
Complies with licensure requirements.

Education
Master's Degree Social Work required

Can this role accept experience in lieu of a degree?
No

Licenses and Credentials
Licensed Independent Clinical Social Worker [LICSW - State License]

Experience
Clinical social work experience 5-7 years required

Knowledge, Skills and Abilities
- Exemplifies expert depth of specialized clinical diagnoses and interventions.
- Is routinely sought out by team members for consultation on complex cases and conflict resolution.
- Demonstrates expert clinical assessment and diagnostic skills. Acts as role model; mentors other staff on this skill.
- Demonstrates advanced utilization of clinical skills and interventions and consistently contributes to training and education of staff. Acts as a role model for others, mentoring and training staff in skills.
- Demonstrates highest degree of leadership, flexibility, communication, independence, and teamwork. Is expected to provide significant contributions to education, training and clinical supervision.
- Leads or actively participates in clinical practice inquiries, teaching, projects, or research demonstrating expertise and depth of knowledge of social work practice and skills.
- May participate in the recruitment, onboarding and retention processes.
- Completed LICSW requirements.
- Leads department/service initiatives; participates in initiatives at an Enterprise and Professional Association level.
- Uses data to define baseline issues and measure progress.
- Oversees collaboration and education among all disciplines and outside stakeholders to enhance patient care.

Skills, Abilities, Competencies

Knowledge of specific medical and psychiatric illnesses, procedures and treatments, related medications (i.e., psychotropic, chemotherapy, etc.), acuity versus chronicity, effect on normal growth and development specific to service.

Ability to rapidly conduct and develop comprehensive biopsychosocial assessments responsive to age-appropriate patient/family needs and concerns.

Ability to provide short term or long-term treatment/management of individuals, families, couples and groups.

Exceptional organizational skills and ability to prioritize effectively to complete work in a timely way in the acute care environment.

Strong assessment, crisis intervention and treatment skills.

Ability to communicate effectively orally and in writing.

Strong interpersonal skills enabling effective collaboration.

Competence in assessing and intervening in abuse/neglect, violence, trauma, grief, loss and bereavement.

Competence working with people from diverse racial, ethnic, and socioeconomic backgrounds.

Demonstrates ability to understand the role of a clinical social worker in a health care setting, highly motivated and capable of performing effectively in a complex, fast-paced environment.

High degree of flexibility, independence, ability to prioritize multiple acute concerns, advanced management skills, Strong sense of initiative and perseverance to carry through to completion of tasks.

Develops an effective working relationship with patient/family to engage, collaborate, advocate and problem solve to enhance their functioning.

Develops effective working relationships with interdisciplinary colleagues, multiple rotating care teams, internal collaterals, and external collateral agencies to engage, collaborate, advocate and problem solve to optimize a plan of care, reduce length of stay and avoid readmission.

Demonstrates competency in age specific behaviors, cultural issues and the impact of illness on patients/ families.

Provides consultation, information and professional support to interdisciplinary team members and social work colleagues.

Shares knowledge of community agencies and resources.

Ability to navigate complex systems with patients/families and to effectively advocate on their behalf.

Demonstrates initiative and leadership to drive the psychosocial plan of care in response to patient care needs.

Documents in medical record according to Departmental policies and procedures.

Maintains patient/family confidentiality in accordance with HIPAA and MGH policies.

Ability to consult and teach.

The General Hospital Corporation is an Equal Opportunity Employer. By embracing diverse skills, perspectives and ideas, we choose to lead. All qualified applicants will receive consideration for employment without regard to race, color, religious creed, national origin, sex, age, gender identity, disability, sexual orientation, military service, genetic information, and/or other status protected under law. We will ensure that all individuals with a disability are provided a reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment.