Care Navigation Social Worker- Bryan Palliative Care

Responsible for collaborating with health care team members to identify and plan for the complex and problematic psychosocial needs of the patient and family. Assists patients and families in adjusting to the demands of chronic health care needs across the continuum. Serves as a resource to the inter-disciplinary team. Provides support and case consultation to other care navigation team members when complex issues arise, working in Palliative Care includes providing psychosocial, emotional, and practical support to palliative patients and their families and to advance competence of palliative psychosocial care across Bryan Health.

PRINCIPAL JOB FUNCTIONS:

• *Commits to the mission, vision, beliefs and consistently demonstrates our core values.
• Serves as a resource to the inter-disciplinary team and Care Navigators in meeting complex needs of patients.
• Maintains professional relationships and communicates effectively with other members of the inter-disciplinary team, as well as community service agencies.
• Assists patients/families in understanding, accepting and following medical recommendations.
• *Facilitates communication with patients/families from a wide variety of developmental and social/cultural backgrounds; conveys an attitude of acceptance, sensitivity and caring.
• *Advocate for self-determination and culturally appropriate care to ensure wishes and needs of the patient and family are respected.
• Assists with advance care planning as defined by the patient and family.
• *Helps navigate access to resources for financial needs, health insurance coverage, medical costs, bills, disability and other financial stressors for patient and family.
• *Recognizes signs and symptoms of anxiety, guilt and depression. Provides interventions through education, short term therapy, problem solving techniques. Provides brief behavioral interventions using evidence-based techniques such as behavioral activation, problem-solving treatment, motivational interviewing, or other treatments as appropriate.
• *Supports the mental and physical health care of patients on an assigned patient caseload. Closely coordinates care with the patient's medical provider and, when appropriate, other mental health providers.
• *Screens and assesses patients for common mental health and substance abuse disorders. Facilitates patient engagement and follow-up care. Provides patient education about common mental health and substance abuse disorders and the available treatment options.
• Systematically tracks treatment response and monitors patients (in person or by telephone) for changes in clinical symptoms and treatment side effects or complications.
• Supports psychotropic medication management as prescribed by medical providers, focusing on treatment adherence monitoring, side effects, and effectiveness of treatment.
• *Participates in regularly scheduled (usually weekly) caseload consultation with the psychiatric consultant and communicate resulting treatment recommendations to the patient's medical provider.
• *Documents patient follow up and clinical outcomes using an electronic health record and other systems as required.
• *Facilitates treatment plan changes for patients who are not improving as expected in consultation with the medical provider and the psychiatric consultant and who may need more intensive or more specialized mental health care.
• *Facilitates referrals for clinically indicated services outside of the organization (e.g., social services such as housing assistance, vocational rehabilitation, mental health specialty care, substance abuse treatment).
• *Maintains professional growth and development through seminars, workshops, and professional affiliations to keep abreast of latest trends in field of expertise.

In addition to the principal job functions contained on the primary job descriptions, the following duties are also required in the department noted above.

• Facilitates anticipatory planning for grief and bereavement. Helps patient and family identify coping skills through past strengths and current support systems.
• Works collaboratively with hospital care management to identify potential discharge needs and works constructively to problem solve and identify possible solutions to ensure seamless transitions of care.
• Participates in IDT and multidisciplinary rounds.
• Serves as a liaison between palliative care team and community hospice or home health agencies, long term care facilities.
• Participates in relevant didactic sessions and quality improvement initiatives.
• Comprehensively analyzes patient and family situations that will require advanced advocacy with knowledge of community resources.

EDUCATION AND EXPERIENCE:

Certification as a Licensed Clinical Social Worker (LCSW) or current license as a Licensed Mental Health Practitioner (LMHP) by the State of Nebraska required. Master's degree in Social Work (MSW) preferred. Minimum of two (2) years prior case management experience required. Prior Palliative Care or Hospice experience strongly preferred.