Social Worker - Primary Care

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Social Worker - Primary Care --------------------------------------------------------------- The Social Worker is responsible for delivery of social work services to patients, including psychosocial evaluations, ongoing counseling, casework services, coordination of referrals, transitions, and potentially palliative care and bereavement services. These patients may have advanced illnesses and often have other complex medical/psychosocial/addiction issues. The Social Worker provides support and care for patients in various settings including: all types of patients' home settings, assisted living residences, shelters, hospitals, emergency departments, skilled nursing facilities, clinics, and specialty settings. NOTE: This position will cover NE Portland and St. John's area. Estimated Hiring Range: $44.26 - $54.09 Bonus Target: Bonus - SIP Target, 5% Annual Current CareOregon Employees: Please use the internal Workday site to submit an application for this job. --------------------------------------------------------------- Essential Responsibilities Conduct comprehensive psychosocial assessments and make appropriate referrals to community resources as well as provides education to patients and families regarding community resources, benefits and entitlements. Collaborate with clinical and support staff regarding patient/family/caregiver issues. Conduct patient and family counseling and education considering family system/dynamics and coping methods to all age groups and make appropriate referrals to other community resources if indicated. Help patient and family/caregiver develop coping strategies to manage declining physical health, and emotional or spiritual needs. Closely partner with patient providers and interdisciplinary care team across the continuum to facilitate care that meets the individual's personal needs, values, and preferences. Provide short-term crisis intervention and assume active role of advocate for family. Assist clinicians and clinical teams with management of transitions of care when patients are moving from one setting to another, including (but not limited to) from place of residence to hospital or nursing home and back, assisting with placement as needed. Provide direct patient care support in a variety of settings. For those working closely with advanced illness patients, the Social Worker will utilize palliative care principles, trauma informed care, motivational interviewing and case management strategies. Participate as a member of interdisciplinary care team assisting with establishing and implementation of psychosocial care plan in patients with serious, complex and/or chronic illness which could include partnering with Primary Care, Hospice or AIC team members. Assist patients and family with advance care planning which includes discussions about goals of care/treatment, answering general questions about power-of-attorney documentation, the POLST form and the Oregon Advanced Healthcare Directive Form. Communicate and coordinate with other providers to ensure care is coordinated and consistent with patient's goals of care, including AD/POLST. Assist with establishment of POA-HC (power of attorney for health care) and with establishment of end-of-life care plans as needed. Provide education to patients, family members, caregivers and Housecall Providers' staff regarding mental health issues, grief, resiliency, hospice services, community resources, benefits and entitlements. Provide consultation on ethical issues that arise for HCP staff. Conduct mental status exams (e.g., MMSE, SLUMS, MoCa) as requested by Providers. Provide advocacy for patients and families with various community agencies, care facilities and other institutions as needed. Assist clinicians with organization and/or facilitation of care conferences for assessment, education or conflict management. Experience and/or Education Required Master's degree in social work from an accredited college Current Oregon LCSW, LMSW or CSWA license Minimum 1 year work experience in geriatrics, home health, hospice, hospital, primary care/specialty care clinic or other community based mental health or outreach social work Valid driver's license, acceptable driving record, and automobile liability coverage or access to an insured vehicle CPR certification at hire or within 6 months in position Preferred Experience dealing with substance use disorders, care coordination and needs assessment for high- risk populations Knowledge, Skills and Abilities Required Skills and Abilities Practice within the scope of license where applicable, and as required by law and regulation. Ability to assess psychosocial needs, establish and implement a social work plan of care, triage urgent and crisis situations, and stay focused Ability to be sympathetic to a patient, family or caregivers needs, and be able to deal with people in various states of pain, trauma and tragedy For those working with advanced illness patients, employees must feel co

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