Ambulatory Care Mgmt Social Worker

Collaborates with PCP & multidisciplinary team to support patient populations with chronic illness, and multiple comorbidites. The care manager - SW understands and adheres to established care management standards that incorporate evidence based protocols, cost effective, and patient focus targeted interventions.

Applies Social Work methods to skilled assessment, education, collaboration, and coordination of healthcare and community resources to achieve the following: assist patients to gain self-efficacy/management skills, achieve optimal functional health status, and improve quality of life.

Assists patient/families, care team, and systems to achieve high quality, outcomes through telephonic, in person, and/or home visits. Is knowledgeable regarding community and government agencies, support groups, and provides linkages with appropriate TriHealth and community referrals.

Providing support services to the PHO and all of its value-based contract members including but not limited to care coordination, home health visits, and counseling.

Job Requirements

Bachelor's Degree in Social work, Addictions, Counseling (Required) 3 - 4 years years experience (Required) LCSW- License Clinical Social Worker Required

Job Responsibilities

Assesses, plans, implements, monitors, and evaluates delivery of individualized, patient-centered care with the goal of optimizing the patient’s health status through connection with available support systems, community resources, care coordination with necessary specialists, and patient education. Develops plans to address psycho-socio-economic and/or behavioral issues.

Communicates and collaborates with PCP and clinical staff regarding the patient’s psycho-social barriers to health maintenance and assist in coordinating and supporting referrals to indicated services.

Interacts with clinical and medical personnel across all hospital inpatient and outpatient service lines to ensure collaboration across care settings and meaningful integration at transition points. Provides end of life discussions and initiates referrals for palliative care and Hospice.

Contributes to individualized care for identified patients, focusing on psychosocial assessment and setting goals to meet identified needs. Assess progress toward goals, support evidence based clinical protocols and plan of care, and addresses barriers to progress. Completes required documentation of above.

Works with high risk patients to provide targeted interventions to improve health outcomes. Coordinates care across settings and helps patient/families understand health care options. Promotes patient self-management support with a focus on empowering the patient/family to build capacity for self- care in order to achieve optimal health and independence.

Utilizes registries, reports and tools to identify target populations and patients. Plans for and manages a panel of patients with chronic/complex disease(s); plans interventions appropriate to patients' diagnoses, age, abilities and resources; establishes and implements patient directed learning and supports disease self-management care plan for patient/significant others to enhance therapuetic outcomes.

Participates in quality improvement initiatives; activities may include data collection, chart review, interdisciplinary collaboration, analysis of patient data and inter-professional staff meetings.

Working Conditions

• Bending -
• Climbing - Rarely
• Concentrating - Frequently
• Continuous Learning - Frequently
• Hearing: Conversation - Consistently
• Hearing: Other Sounds - Frequently
• Interpersonal Communication - Consistently
• Kneeling - Rarely
• Lifting <10 Lbs. - Frequently
• Lifting 50+ Lbs. - Rarely
• Lifting <50 Lbs. - Occasionally
• Pulling - Rarely
• Pushing - Rarely
• Reaching - Rarely
• Reading - Frequently
• Sitting - Frequently
• Standing - Rarely
• Stooping - Rarely
• Talking - Consistently
• Thinking/Reasoning - Consistently
• Use of Hands - Frequently
• Color Vision - Frequently
• Visual Acuity: Far - Frequently
• Visual Acuity: Near - Consistently
• Walking - Frequently

TriHealth SERVE Standards and ALWAYS Behaviors

At TriHealth, we believe there is no responsibility more important than to SERVE our patients, our communities, and our fellow team members. To achieve our vision and mission, ALL TriHealth team members are expected to demonstrate and

live the following:

Serve: ALWAYS...

• Welcome everyone by making eye contact, greeting with a smile, and saying "hello"
• Acknowledge when patients/guests are lost and escort them to their destination or find someone who can assist
• Refrain from using cell phones for personal reasons in public spaces or patient care areas

Excel: ALWAYS...

• Recognize and take personal responsibility to address and recover from service breakdowns when a customer's expectations have not been met
• Offer patients and guests priority when waiting (lines, elevators)
• Work on improving quality, safety, and service

Respect: ALWAYS...

• Respect cultural and spiritual differences and honor individual preferences.
• Respect everyone's opinion and contribution, regardless of title/role.
• Speak positively about my team members and other departments in front of patients and guests.

Value: ALWAYS...

• Value the time of others by striving to be on time, prepared and actively participating.
• Pick up trash, ensuring the physical environment is clean and safe.
• Be a good steward of our resources, using supplies and equipment efficiently and effectively, and will look for ways to avoid waste.

Engage: ALWAYS...

• Acknowledge wins and frequently thank team members and others for contributions.
• Show courtesy and compassion with customers, team members and the community