Adult Medical Social Worker - Southern Jamaica Plain Community Health Center

Site: The Brigham and Women's Hospital, Inc.

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Job Summary

• SIGN ON BONUS AVAILABLE for eligible Non-MGB employees:
• $3,000 for LCSW and $10,000 for LICSW

The Adult Medical Social Worker is a key member of the interdisciplinary team who oversees and provides behavioral and psychosocial care for patients and families who receive care at Southern Jamaica Plain Community Health Center (SJPCHC). The clinician engages collaboratively with patients, families and the health care team to identify patient priorities, address psychosocial needs and structural and systemic barriers to care, and develop strategies that support patient goals and physical and behavioral health outcomes.

The Medical Social Worker is responsible for biopsychosocial assessment and providing intervention and treatment as indicated, as well as clinical case management, care coordination and outreach for adult patients and their families. Referrals come primarily from medical providers and Behavioral Health (BH) clinicians and often involve complex medical and behavioral health needs. Services include risk assessment, brief interventions, crisis intervention, psychotherapy, supportive counseling, advocacy, education and resource information and community referrals. This includes Flexi Care services for patients with complex behavioral health needs who fall outside usual BH treatment criteria, with care tailored to their needs. The clinician provides bridging clinical support, case management and treatment while patients await connection to community services. Treatment plans are guided by patient goals and collaboration with the multidisciplinary team and evaluated and revised as necessary. The clinician provides clinical care in the community health setting in a hybrid model (some days in the office and some off site). Like other departmental clinicians, the clinician participates in designated BHL shifts and health-center-wide behavioral health emergency pager coverage. The role requires substantial independence and initiative, supported by robust clinical supervision, consultation and interdisciplinary learning. Clinical supervision toward applicable licensure is provided.

Qualifications

PRINCIPAL DUTIES AND RESPONSIBILITIES

1. Conducts assessment, triage, stabilization and brief interventions with patients and families, incorporating the social, emotional, cultural, environmental and financial factors affecting each individual and family system. Participates in designated Behavioral Health Live (BHL) triage shifts as a shared responsibility of departmental clinicians, conducting brief assessments for the BH department, the Healing Recovery and Wellness (HRW) program and referrals to the Adult Medical Social Worker. Participates in designated emergency pager coverage for behavioral health emergencies throughout the health center.

2. Provides short- and long-term therapy, brief interventions to patients as appropriate, including Flexi Care patients with complex behavioral health needs. Treatment may bridge care or continue longer term based on patient needs and clinical assessment. Develops treatment interventions that may range from advocacy, counseling or crisis intervention, short- or long-term treatment, and assistance with concrete services. The clinician will present cases to the adult clinical team and adhere to billing compliance expectations and provide necessary diagnostic information.

3. Provides outreach and follow-up to high-risk patients/families, including helping patient access a higher level of care: hospitalization, partial hospitalization, including coordination of referrals out to community resources.

4. Works collaboratively with patients and families to communication patterns and decision-making that affect engagement in care, recognizing patient preferences, strengths and barriers to following treatment plans.

5. Provides advocacy and liaison services to community resources as needed.

6. Refers patients/families to Behavioral Health (BH) department for individual or family psychotherapy. The Adult Medical Social Worker can hold up to 8 BH therapy cases followed in the BH department as negotiated with BH director. These cases may include both bridging and longer-term psychotherapy, based on patient needs and clinical assessment.

7. Acts as the liaison between Adult Medicine, Family Medicine, BH, and the Health Promotion Center (HPC), collaborating with the patient’s full care team, including external providers and state and community agencies. Attends BH adult clinical team meetings and relevant community meetings (All staff attendance once a month, All staff education meeting attendance 4 times a year).

8. Coordinates care and assists with behavioral health referrals in house and with external providers. Provides bridging clinical support, case management and treatment when waitlists or service limitations delay access, and follows up to support continuity and transitions in care.

9. Collaborates across departments to provide coordinated care for patients. Provides direct case management, resource education and referrals for patients/families needing transportation, financial, legal, immigration or vocational services. Partners with patients to address structural and systemic barriers to accessing these services and provides interim support when community resources are unavailable or delayed.

10. Meets with providers and attends provider meetings as needed.

11. Clinical documentation of all services provided, including in-house at health center, community referrals and virtual/ telephone outreach. Billing compliance to close encounters within 5 business days-unless a BH emergency to be documented day of the incident.

12. Assists clients and families in navigating the health care and social service systems and reducing barriers to care in and out of the health center.

13. Attends departmental meetings and relevant community meetings.

14. Other responsibilities as assigned by BH director.

Additional Job Details (if applicable)

QUALIFICATIONS

1. Master’s degree in Social Work with LCSW or LICSW licensure, or eligibility for LCSW licensure consistent with position requirements; alternatively, a qualifying graduate degree and current LMHC licensure. Experience with adults preferred. Robust clinical supervision toward LICSW licensure is provided for eligible social work clinicians. Counseling applicants must already hold an LMHC, as the department does not currently offer structured supervision pathway toward initial LMHC licensure.

2. 1-2 years’ experience in social service, health care or community work preferred; relevant graduate field placement experience is considered. Recent graduates are encouraged to apply.

3. Bilingual in Spanish and English required.

SKILLS AND ABILITIES REQUIRED

1. Demonstrates cultural humility and a patient-centered, health equity approach to clinical care. Ability to work respectfully with people across race, ethnicity, age, class, sexual orientation, gender identity and other identities and experiences. Recognizes and addresses structural and systemic barriers that impact health, behavioral health and access to care.

1. Excellent interviewing/listening skills and clinical judgment. Excellent crisis

intervention skills.

3. Ability to communicate well both orally and in writing.

4. Excellent time management and organizational skills.

5. Ability to work with a high degree of independence, exercise sound clinical judgment and take i