This Licensed Clinical Social Worker (LCSW) is responsible for providing screening, health coaching and focused, intervention and consultation to the medical team for patients seen in primary care with behavioral health conditions. Specifically, this position will partner with primary care providers to identify patients who have psycho/social needs on an outpatient basis. The LCSW will be developing patient care goals and treatment plans as agreed upon by the patient's primary care team. The LCSW is also available to primary care teams as a consultant for those patients with unique psychosocial needs.
Essential job duties and responsibilities:
Evaluates, designs, and implements ambulatory case management interventions for patients with psycho/social and/or substance abuse issues with particular focus on patients with mental health needs such as depression and anxiety.
Identifies patients who might benefit from their services and works with primary care teams to provided integrated, coordinated care.
Considers physical, behavioral, and emotional aspects of patient's health.
Coordinates and tracks screening tools assessing emotional wellbeing (i.e: PHQ 9, GAD) and advises PCP when scores reach a given threshold of severity. If any suicidality is reported, advises PCP and/or SW team immediately to activate safety plan.
Helps with planning and implementation of interventions agreed to by patient's primary care team for patients with emotional or behavioral problems such as difficulties with patient's relationships, insomnia, depression, anxiety, grief, excess stress, etc.
Helps patients with lifestyle behavior changes such as diet and nutrition, exercise, and stress management in order to prevent or better handle chronic medical conditions such as obesity, hypertension, etc.
Helps patients with relaxation techniques, stress management, pain management, smoking cessation, social support, self-management (i.e.: supervising physical or behavioral symptoms), medication adherence.
Develops education strategies and specific behavioral change plans for patients and behavioral health protocols for target populations.
Provides clinical diagnosis and intervention directly in the primary care office.
Conducts outreach and engages patients with chronic conditions in order to improve adherence with treatment recommendations and improve health outcomes.
Makes referrals to specialty mental health services and other resources as needed. Consults in regular supervision with mental health medical director to determine when and what level of mental health service referrals are indicated
Documents assessment and recommendations in patient's outpatient medical record.
Attends and participates in meetings and quality improvement activities as required.
Evaluates caseload daily and assess achievement of long and short term goals. Modifies goals with providers based upon patient outcomes. Compiles and present statistics and reports relating to patient outcomes. Documents findings in the patients EHR.
Communicates, provides follow up and outcome communication to the referral source (i.e.: PCP, family member, Case Manager, home health personnel, community social worker, Health Plan, etc.).
Acts as social services liaison between primary care practices and Care Management particularly for patients requiring.
Referrals to agencies which provide appropriate supportive services
Assists in arrangement of community resources (i.e. meals on wheels, transportation services, adult day care, and info-line).
Assists in long term planning for patients transitioning to an institutionalized setting
Provide alternatives for patients requiring specific services while lacking insurance coverage.
Addresses and/or coordinates for the resolution of psychosocial concerns that are hindering patient's care as appropriate.
Provides mentorship, preceptorship, and training to SW colleagues, students and staff as assigned and appropriate.
Providing healthcare for more than 100 years, Cedars-Sinai has evolved into one of the most dynamic and highly renowned medical centers in the world. Along with caring for patients, Cedars-Sinai is a hub for biomedical research and a training center for future physicians and other healthcare professionals. This attracts exceptional talent to Cedars-Sinai, including world-renowned physician-scientists who seek a place where they can both conduct research and see patients--the ideal formula for discovery and its translation into cures. Our patients benefit from access to doctors at the top of their fields, and our researchers have an ideal community in which to study the impact of healthcare challenges, and reflect that knowledge in their research. The greater Los Angeles area in which Cedars-Sinai resides possesses unparalleled cultural and ethnic diversity which offers outstanding opportunities for translational and clinical research... and a dynamic environment for medical education.Although community based, Cedars-Sinai is a major teaching hospital affiliated with the David Geffen School of Medicine at the University of California, Los Angeles (UCLA). Cedars-Sinai has highly competitive graduate medical education programs in more than 50 specialty and subspecialty areas, a graduate program in biomedical sciences and translational medicine, a clinical scholars program directed towards junior physicians with aspirations to become clinical scientists, and post graduate training opportunities.There are more than 250 full-time faculty members at Cedars-Sinai. The voluntary medical staff, comprised of more than 2,200 specialty board-certified or board-qualified physicians, represent all of the specialties and subspecialties and collaborate with full-time medical staff in the teaching responsibilities of the graduate medical education programs.