About Wilmington Health
Since 1971, Wilmington Health has been committed to the care and health of our community in Wilmington as well as all of Southeastern North Carolina. Wilmington Health is structured as a multi-specialty medical practice with primary care providers integrated into the system. In this way, Wilmington Health is able to provide a comprehensive and coordinated approach to the care of all our patients. Wilmington Health is committed to using collaborative, evidence-based medicine in providing the highest quality of care to the patients we serve.
Purpose:
Counsel and provide crisis intervention for patients, including assessment and treatment of emotional and behavioral problems. Assist with discharge planning and consultation about patients and families to assist them and the health care team in coping with patients’ illness, diagnosis, treatment, including emotional, mental and substance abuse disorders. Lead the implementation and maintenance of Advanced Medical Home Tier 3 status for the organization.
Essential Duties/Responsibilities:
Performs comprehensive assessments on patients identified as a priority for care management to determine care needs which includes patients immediate care needs and current services; documentation of state or local services currently used; physical health conditions, including dental; current and past behavioral and mental health and substance use status; physical, intellectual developmental disabilities; medications; and priority social determinants of health (housing, food, transportation, and interpersonal safety.
Develops individualized and person-centered care plans using a collaborative approach including patient and family participation where possible for high-need patients receiving care management within fifteen (15) days of a comprehensive assessment, or sooner if feasible, while ensuring treatment is not delayed by the development of the care plan. Person-centered care plans should include measurable patient (or patient and care giver) goals, medical needs including behavioral health and dental needs, interventions (including medication management and adherence), intended outcomes, and social, educational and other services needed by patients.
Interventions may include crisis intervention, brief and long-term individual, marital, family and/or group therapies.
Works in partnership with clinicians in a team-based approach to provide care management for high-need patients and accountability for active, ongoing care management that goes beyond office-based clinical diagnosis and treatment.
Assist with screening, identification, diagnosis, management, and treatment of abuse, neglect, domestic violence, rape, mental health and/or substance abuse problems in patients and family members.
Provide consultative services to health care team members within scope of care definitions as needed.
Maintain a working knowledge of relevant medical/legal issues that impact on patient care, e.g., advance directives, child, and elder abuse, etc.
Arrange, procure, and coordinate patient/family pre and post appointment needs.
Knowledge of medical center resources to access and provide for patient care needs.
Participate in multi-disciplinary health care teams and provide leadership in representing clinical social work perspective/liaison with patient and family.
Assists in developing, shaping, and maintaining policies, procedures and protocols related to care management for high-need patients and to the greatest extent possible, ensures that the whole care team understands the basis of the practice’s methodology for identifying priority populations for care management and that the methodology is applied consistently.
Maintain working knowledge of and liaison with community agencies and resources.
Document assessment, plan, interactions, and interventions according to hospital and departmental guidelines and standards.
Maintain confidentiality around patient and family information.
Participate in department, and medical center continuous quality improvement efforts.
Participate in regular staff, supervisory and department meetings; keep current with social work and health care developments and seek to increase further enhancement of job-related knowledge.
Partners with practice’s population health team to provide insight, direction, and scrutiny related to risk stratification methodologies for identifying priority populations and high-need patients which is consistent throughout the practices and in compliance with payer contracts.
Works in partnership with clinicians, practice leadership, care team members, and population health team members to periodically evaluate care management services provided to priority populations and high-need patients to ensure that services are meeting the needs of empaneled patients and refine the care management services as necessary.
Develops processes to respond to outreach from emergency departments (ED) relating to post ED admission or discharge decisions or hospital inpatient care teams relating to post discharge decisions. Decisions should include plans for same-day or next-day outreach for designated high-risk subsets of the priority population using the practices risk stratification methodology.
Develops protocols for providing short-term transitional care management that goes beyond office-based clinical diagnosis and treatment, including medication reconciliation, for high-need patients who are at risk of readmission and other poor outcomes
Develop processes, policies, and system to meet the requirements to meet and maintain Tier 3 Medical Home status. Coordinate and collaborate with appropriate providers, staff, leadership, and community entities including payors to meet all standards and effectively service patients and their families.
Other Duties:
As assigned by manager
QUALIFICATIONS
Required:
Master’s degree from an accredited school of social work
Current licensure as a licensed clinical social worker by the NC Social Work and Certification and Licensure Board
3 or more years of social work experience in a health care setting or social services agency with one of the three years may be social work internship.
Full COVID 19 vaccination is required as a condition of employment for all position with Wilmington Health. Documentation is required prior to orientation.
Wilmington Health is an Equal Opportunity Employer committed to providing equal opportunities to all applicants and employees. We are committed to treating everyone equally and with respect regardless of race, age, sex, religion, national origin, citizenship, marital status, veteran’s status, sexual preference, disability, genetic information or any other class protected under state or federal law.
ADA Physical Demands:
Rarely (Less than .5 hrs/day) Occasionally (0.6 – 2.5 hrs/day) Frequently (2.6 – 5.5 hrs/day) Continuously (5.6 – 8.0 hrs/day)
Physical Demand Required? Frequency
Standing Occasionally
Sitting Continuously
Walking Occasionally
Kneeling/Crouching Rarely
Lifting Rarely
