Works under the supervision of the Palliative Care Team.
Serves in an expanded role to collaborate with patients, Palliative Care Providers, practice teams, all community agencies, including, but not limited to, behavioral health, housing authorities, Department of Health and Human Services, transportation and home health organizations, and other medical/specialty services to provide a model of care that ensures the delivery of quality, efficient, and cost-effective healthcare services. Assesses patient needs from a strengths based, person in environment manner, to design and implement coordinated intervention plans that monitor and evaluate options and services that aid towards meeting the shared goal of optimizing the patient’s physical and bio-psycho-social-spiritual health status and lowering avoidable costs associated with less than optimal health and/or misuse/overuse of medical/community based services.
The Social Worker works collaboratively within EMMC care coordination program and all care team members to ensure patient needs are met and care delivery is coordinated, and not duplicated, across the healthcare continuum. The expertise of the Social Worker is sought to assess and intervene with bio-psycho-social-spiritual barriers to patient’s engaging with the healthcare system in a manner that promotes optimal health. Utilizes shared decision making models, collaboration, motivational interviewing, and other evidence based patient engagement, activation, and care coordination interventions to encourage positive behavior change in order to assist patients to achieve their highest level of function.
1. Assists to develop coordinated care plans for patients with complex medical and/or behavioral health needs. Fosters a team approach by working collaboratively with all practice and community based team members, including but not limited to formal and informal supports such as: family members, neighbors, primary care providers and other members of the health care team, and community based supports to ensure coordination of services.
2. Assist to identify outreach, wellness and education planning needs of the identified members and communicate findings to the Care Coordinator or CCT Lead.
3. Coordinates referrals between and among physical and behavioral providers to necessary and appropriate community resources to assist patients to meet their goals and improve functioning. Ensures appropriate clinical information is shared timely with peers, providers and outside agencies while adhering to system privacy standards.
4. Provide outreach, including telephonic, meetings or oral presentations, to community based and county transportation (or designated subcontractors) to assist members to access services.
5. Works closely with payers to appropriately apply member benefits and serve as a resource to the member and healthcare team.
6. Adheres to EMMC policies regarding member confidentiality.
7. Maintains required documentation for all patient care activities. Collects required information and utilizes it to perform care coordination and collaborate with all team members to enhance patient care.
8. Works with Palliative Care leadership to continuously evaluate process, identify problems, and propose process improvement strategies to enhance the Community Care Team, Patient Centered Medical Home, and Health Home Programs.
9. Incorporates excellent written, verbal, and listening communication skills, positive relationship building skills, and critical analysis skills into social work practice.
10. Performs social work activities, as set forth herein, in a variety of settings, including, but not limited to PCP offices, patient homes, hospital, or other community based settings as deemed appropriate for each individual high risk or complex patient in collaboration with Care Coordinator, contracted home health agency or primary care provider and all other service and health providers who the patient is working with.
11. Develop collaborative relationships with community based agencies to understand and disseminate program and service eligibility, thus allowing for efficient use of referral systems aimed at improving care.
12. Utilizes appropriate conflict resolution, assertiveness, advocacy, brokerage, negotiation, and collaboration skills in facilitating patients’ movement throughout the health care continuum.
13. Acts as a care partner to Care Coordination, Patient Centered Medical Homes and Health Home programs to assist practice members to appropriate referral sources.
14. Participates in all required training and supervision to maintain State of Maine Social Work licensure.
15. Utilizes evidence based screening tools to gather information related to barriers, strengths, and symptoms, which impact patient function. Shares information with practice team in order to enhance and improve outcomes.
16. Performs duties as required or assigned by emergency or other operational reasons for which the employee is qualified to perform.
Competencies and skills:
* 2+ years of relative work experience required.
* Behaves with Integrity and Builds Trust: Acts consistently in line with the core values, commitments and rules of conduct. Leads by example and tells the truth. Does what they say they will, when and how they say they will, or communicates an alternate plan.
* Cultivates Respect: Treats others fairly, embraces and values differences, and contributes to a culture of diversity, inclusion, empowerment and cooperation.
* Demonstrates Adaptability: Learns quickly when facing a new problem or unfamiliar task; is flexible in their approach with changing priorities and ambiguity. Manages change effectively and does not give up during adversity. Capable of changing one’s behavioral style and/or views in order to attain a goal. Absorbs new information readily and puts it into practice effectively.
* Effectively Communicates: Listens, speaks and writes appropriately, using clear language. Communication methods are fitting to the message(s), audience, and situation and follow-ups are regular and timely. Shows that important (non-) verbal information is absorbed and understood and asks further questions to clarify when necessary. Expresses ideas and views clearly to others and has ability to adjust use of language to the audiences’ level.
* Fosters Accountability: Creates and participates in a work environment where people hold themselves and others accountable for processes, results and behaviors. Takes appropriate ownership not only of successes but also mistakes and works to correct them in a timely manner. Demonstrates understanding that we all work as a team and the quality and timeliness of work impacts everyone involved.
* Influences and Inspires: Builds enthusiasm and commitment among others to move in a desired direction and models it personally. Creates a compelling vision of success that motivates workplace initiative and energizes others to follow. Provides direction and guidance to encourage cooperation between team members in order to attain an objective. Has the ability to appropriately influence others’ actions and decisions with and without express authority.
* Practices Compassion: Exhibits genuine care for people and is available and ready to help; displays a deep awareness of and strong willingness to relieve the suffering of others.
* Provides Patient-Centered Care: Demonstrates understanding of patient care quality and service as organizational priority. Proactively supports change to improve patient experience and results. Exhibits the ability and willingness to find out what the patient wants and needs and to act accordingly, taking the organizational and outside resources into account. Cooperates, collaborates, communicates, and integrates care within and between teams to ensure that care is continuous and reliable.