PURPOSE OF POSITION:
The Clinical Engagement Social Worker will work under the direction of the facility-based Program Lead as a member of the Special Populations Care Management Program at NYC H+H. The Clinical Engagement Social Worker is an integral member of an interdisciplinary team within the emergency room (NYC Health + Hospitals Acute facilities) and community to provide in-reach and outreach services that will bridge patients to longitudinal healthcare services and care management. The Clinical Engagement Social Worker interfaces with the healthcare and social services team memberswithin and beyond the emergency room to identify medically appropriate and cost-effective care. The Clinical Engagement Social Worker is a senior member of the Engagement & Navigation team; they will maintain a caseload of patients with more heightened complexity and risk acuities. The candidate in this role is a senior member of the Engagement and Navigation team and will complete mentoring and supervisory tasks as needed to support less senior team members. The Clinical Engagement Social Worker will set an example of approaching care management in a holistic capacity that addresses gaps in care and supports patients to be more self-directed and feel empowered to engage in long-term healthcare resources.
DUTIES AND RESPONSIBILITIES:
The Clinical Engagement Social Worker will be responsible for the following:
Provide direct clinical and administrative supervision, orientation and guidance to social work staff, screen and assign cases, schedule staff ensuring adequate coverage, read and review staff work, evaluate work performance and monitor/ maintain time and leave records.
As a Licensed Clinical Social Worker (LCSW), provides and documents clinical supervision of NYC H+H Licensed Master Social Workers (LMSWs) toward advanced Social Work licensure in alignment with the all relevant professional standards and practices, and in accordance with all applicable NYS licensure laws.
Maintains individualized supervision logs documenting clinical supervision and ensures timely completion of attestation forms required by NYSED Office of the Professions to support LCSW licensure applications, as applicable.
Ensures compliance with accepted social work practices and principles and operational adherence to hospital and government rules/regulations, including compliance with reporting requirements and standards regarding evaluation of staff performance, time and leave regulations and timeliness of documentation.
Screen charts for historical and clinical information, identification of existing community-based linkages, and identification of care coordination opportunities.
Interpret clinical information based on case data, histories, statistics, etc., to prepare and submit comprehensive reports of case findings, including chronologies of medical data and social factors necessary to support recommended courses of action.
Screen and assess for the treatment of serious mental illness (SMI) and substance use disorder (SUD) diagnosis.
Complete psychosocial evaluations and referrals for time-sensitive clinically appropriate interventions (such as but not limited to) referrals to higher levels of care during the ED visit or while completing post-ED outreach.
Provide ongoing support and psychotherapeutic counseling to patients, families, and significant others, as well as concrete services at a frequency determined by the respective assigned area.
Coordinate with the Emergency Department clinical treatment team and Engagement Navigator to assess the patient's presenting symptoms & social context that resulted in an ED visit.
Collaborate with the Engagement Navigator to engage the identified patient and build rapport, assess their level of engagement with current supports, and discuss clinical referrals such as primary care, behavioral health, medical specialty, and longitudinal care models and social services referrals for care management and housing supports.
Confirm the best method for follow-up contact (cell phone number, emergency contact, and field-based location for outreach), and reinforce the discharge plan outlined by the clinical treatment team.
Act as an intermediary between patients and providers for discharge planning by scheduling follow-up appointments, assessing the patient's transportation needs, planning to obtain medication post-discharge, and identifying gaps in care.
Provide complex care management services with a harm reduction and trauma-informed lens prior to linking patients to alternative long-term care model programs within and outside of the H+H system when appropriate.
Maintain a caseload of ED E+N patients with complex care needs post-ED discharge. The Clinical Engagement Social Worker will help address gaps in care post-discharge by scheduling appointments, providing reminders before the appointment, and supporting the patient with linkage for longitudinal care management.
Conduct fieldwork outreaches within the community to bolster patient engagement with longitudinal healthcare resources.
Complete outreach activities as required for E+N patients not actively engaged in treatment, such as diligent search activities.
