Transitional Care Housing Program - Oregon Health & Science University
Portland, OR
About the Job
The Clinical Outreach Social Worker (COSW) uses advanced clinical and/or healthcare operational subject matter expertise combined with systems and workflow knowledge to manage and assist in compassionate interventions to patients with complex psychosocial needs who discharge from OHSU Emergency Department and hospital. The COSW prioritizes clients with limited connections to outpatient services and frequent ED encounters. This population is growing in numbers, cost and complexity. This work requires unique skill set, flexibility and vast network of community partners to be able to effectively offer care. Job responsibilities include identifying enrollees, conducting needs assessments, identifying appropriate resources, and facilitating service engagement via face-to-face outreach and phone contact. Assessments and services are offered in the ED, hospital, on the streets and in homeless camps, in patient homes, outpatient clinics, and other community settings. The COSW coordinates treatment efforts with other OHSU departments, partners, community partners and affiliates to advocate for client needs. Interventions aim to reduce unnecessary hospital and ED visits by improving access to medical care, substance use disorder treatment, mental health services and housing. While assisting clients in accessing services, the COSW identifies client strengths, models problem-solving skills, encourages mutual participation, and enhances self-advocacy abilities. The COSW participates in data collection for program evaluation purposes and partners with other team members to ensure effective implementation of services. The COSW’s values and care delivery are consistent with the NASW code of ethics.
Specialty Addendum for this Transitional Housing COSW position: The TH COSW will provide specific direct service supports to patients in both the inpatient units and in the community to facilitate patients getting the appropriate level of care and resources. This Transitional Housing Clinical Outreach Social Worker will be supporting the Transitional care teams and TC motels, and will including hospital in-reach and in person community based outreach supports. This position will take lead on inpatient social work discharge planning and outreach care coordination for patients identified as participants in one of the OHSU Care Management Transitional care service lines (motels, RCP, AFH, ICF, etc).
This position is a flexible work position, which allows some remote work. Remote work at OHSU is a work arrangement under which an employee performs the duties and responsibilities of their position, and other authorized activities, from a non-OHSU location as part of their approved, regular work schedule. The Social Worker generally is expected to be in person at least half of their work time, depending on the expectations of their specific position. The social worker should have a private space at home, dedicated to work, and no Protected Health Information should be printed. Social Workers are expected to see patients in person, when at all possible, which may require coming to the hospital at short notice on a remote day.
Salary Range: $90,686 to $137,322
Function/Duties of Position:Intensive Clinical Management
- Care planning: COSW assesses patients for psychosocial and transitional care needs and participates in developing patient-centered care plan. COSW assists patient in identifying goals and recognizing associated behavioral modifications. COSW acts as a liaison between patient and medical team when necessary and contributes clinical expertise to care plan, offers recommendations for diagnosis and treatment of mental health and addresses addictions issues when appropriate. For patients without established primary care, COSW facilitates linkage to clinics that best meet patient’s needs. COSW may arrange appointments, complete intake paperwork, plan transportation options, accompany client to appointments, and support the patient and clinic staff during initial transition period. COSW often provide high level clinical care planning to outpatient community providers, and support both the patient and the clinics while during this engagement period. COSW support prescribers with having detailed understanding of patient’s care needs and care needs outside of the clinic or hospital setting.
- Coordination of care: COSW facilitates cross-site communication between hospitals, clinics, and other community agencies. If patient returns to ED/hospital, SW serves as a source of knowledge about patient’s goals, care trajectory, post-discharge needs, and barriers to outpatient care. COSW acts as a point of consistency between systems to improve patient experience. COSW are required to be effective in working within the outpatient, inpatient, emergency department and other crisis based services. COSW composes and/or updates EDIE care guidelines to increase cross-system knowledge of care plan. COSW often are asked to be content experts and lead facilitator for community-based care conferences with multidisciplinary providers and organizations. COSW are asked to provide other professionals with clinical background and recommendations on how to proceed with a highly complex and traumatized patient.
- Strategic Partner Facilitation: Facilitates integration of OHSU partners into OHSU Care Model. Seeks to understand our community and hospital partner’s clinical objectives and operating challenges and works to maximize their performance and resolve problems. Creates a clinical partnership that aligns objectives and optimizes performance for both OHSU and partners
- Clinical services: COSW offers clinical expertise to medical providers when relevant to drive effective diagnosis and treatment of mental health, substance use disorders, and to provide basic medical care to those experiencing homelessness. COSW are considered to be specialists in providing care to this vulnerable population. COSW provides intensive outreach and engagement to access needed community services, providing education, counseling and motivational interviewing to enhance outcomes of recommended supports and interventions. COSW builds rapport with the patient, modeling patient, modeling empathy and unconditional positive regard. Use of therapeutic techniques, by creating mutually agreed upon goals, help the patient enhance physical, psychological and social functioning. COSW practice interpersonal communication and system navigation skills alongside the patient. S/he provides positive reinforcement for behavioral modifications. COSW have a unique role when providing longitudinal care to those requiring palliative care and hospice based services.
- Case management: Assists patients in securing services to stabilize housing, obtain employment, access financial entitlements, treat addictions issues, and meet basic physical needs. Performs outreach by phone and in person to connect patient to services and increase participation in care. COSW maintains state of the art knowledge of social services in the Tri-County area, including but not limited to shelter access, medical insurance, housing resources, MAT programs, and specific mental health treatment options. COSW makes relevant referrals, advocates for services, and participates in systems-level decision-making when possible.
- Clinical Practice: Participation in standards development. Defined patient outcomes are achieved through provision of expert information, recommendations and collaboration in care and clinical practice. Serves as a clinical consultant for OHSU physicians, nursing staff, RN CMs, inpatient and clinic Social Workers and patients. Collaborates with patient/family and members of the multidisciplinary team in the development, implementation and evaluation of a Patient Plan of Care. COSW streamline patient continuum of care transitions and logistical issues, by provide liaison role between inpatient and outpatient providers. COSW provides education to patient/family in order to assist with patient-led discharge goals. Assesses patients’ SUD, MH and physical healthcare treatment options, as needed. Assesses patient/family understanding of ED/Inpatient admission Discharge Instructions and follow-up Care.
- Interface with insurance companies: COSW must be highly knowledgeable of insurance coverage needs, requirements and processes. COSW must be able to independently facilitate prior authorizations and be able to provide clinical justification and documentation when needed. The COSW work with highly complex patients, often whose care needs and behavior are viewed as too complex for existing outpatient services/providers. COSW submits complex care need requests for flex funding with clinical rationale. COSW are required to be able to navigate both the physical and behavioral-based insurance care needs. COSW are able to provide clinical interventions and recommendations for physical, mental health, substance use, and housing-based services.
- Social Determinants of Health (SDOH): COSW are content experts in identifying, care planning and intervening to address the numerous disparities the target population faces with regards to SDOH. COSW are able to assess and identify needs, make referrals to services, support engagement with referred services and provide feedback to the hospital leadership about care needs. Providing higher level teaching and mentorship on assessment and resources availability to hospital and community based social workers, nurses and physicians.
Data
- Quality improvement: COSW maintain independent preparation of data, design and collection in collaborating with teammates on an ongoing basis to evaluate program effectiveness. COSW solicits feedback from patients, interdisciplinary colleagues, and community partners to improve service delivery. COSW work to add to the overall knowledge of the hospital staff to have the needed expertise to engage in care to a population that can face barriers in engagement and have resounding care needs.
- Quality/Care Services: Leadership is provided in the utilization of Continuous Quality Improvement (CQI) principles to continuously improve and evaluate innovation for high risk, high volume patients and/or system variances. Participates in CQI activities. Utilizes quality indicators in ongoing program development. Facilitates patient movement through the OHSU system, coordinates and facilitates quality related throughput, and balances need for services that are both financially viable and effective. COSW support physicians, nurses, social workers and other staff to recognize and address the moral distress that they experience in working with this population. Providing effective, easily accessible and collaboration supports the ongoing enhancement of staff wellness. COSW support the hospital efforts to work on the Quadruple Aim. Provider services that demonstrate financial savings to both the hospital system and the insurance companies.
Education and Training
- Continuing education: COSW maintains active clinical licensure and obtains required CEUs. COSW participates in continuing education as a learner but also accepts opportunities to provide cross-disciplinary education via rounds, committees, conferences, and presentations when relevant opportunities aris
- Patient, Family and Provider Education: COSW provide psychoeducation to patients and/or their families, and providers that we directly work with. Collaborates with members of the interdisciplinary team including physicians, clinic and hospital personnel to be able to accurately understand care needs of our patients and to be effective in communicating with patients and supports. COSW often acts as an intermediary liaison between providers and patients to find shared goals and recommendations. Provides patient/family with resource contact information as needed, and supports efforts to access and engage in these services. COSW offer coaching, mentoring, training to medical, nursing and social worker students, as well as to fellow colleagues and peers at OHSU. This training is focused on resources availability but also in clinical delivery of care with population with complex care needs.
Master’s in Social Work
3+ years of professional experience diagnosing, treating and advocating for adults with mental illness and co-occurring substance abuse disorders in medical or community mental health settings. Experience working within the Portland social service community and extensive knowledge of community resources.
Experience working with an under-served adult population experiencing mental illness, substance abuse and chronic illness. Strong communication (written and verbal) and organizational skills; works well as part of an interdisciplinary team, is pro-active, flexible and is a solution-focused problem-solver.
Assessment Proficiency
Short-term Counseling
Crisis Intervention
Excellent task Prioritization
Effective Communication Skills
Proficiency and skill in providing social work services in a healthcare setting
Time Management
Organization
Patient Advocacy
Problem Solving
Creativity
Adaptability
Critical thinking
Conflict Resolution
Task Reprioritization
LCSW, in the State of Oregon;
Valid OR/WA driver’s license with an acceptable driving history and access to a car on a daily basis for home visits
- Ability to perform the job duties with or without accommodation.
5+ years of professional experience diagnosing, treating and advocating for adults with mental illness and co-occurring substance abuse disorders in medical or community mental health settings.
Experience working within the Portland social service community and extensive knowledge of community resources.
Experience conducting home visits and street outreach.
Familiar with street safety assessment and crisis interventions and response.
Post Graduate training and certification applicable to the job