The Social Work Care Coordinator works within the context of a primary care medical home, from a team approach, and in continuous partnership with families and physicians to promote: timely access to needed care, comprehension and continuity of care, and the enhancement of child and family well-being. Provides care and treatment where applicable by utilizing critical thinking skills and social worker expertise in order to optimize patient outcomes amongst designated populations within the practice.
Works with patients and families to ensure both behavioral and psychosocial needs are met in order to promote health and well-being. Provides Care Coordination in the Primary Care setting by utilizing critical thinking skills and social worker expertise in order to optimize patient outcomes amongst designated populations within the practice. Addresses gaps in care and promotes timely access to appropriate care, increasing the utilization of preventative care and healthy behaviors to improve the health of the population at risk.
Essential Functions-
Assist with or promote the identification of patients in the practice with special health care, Behavioral Health, and chronic illness needs. Will act as a liaison within the primary care practice team. Monitors and utilizes registries to plan and monitor care including but not limited to chronic/preventative patient registries/lists.
Initiate family contacts; create ongoing processes for families to determine and request the level of care-coordination support they desire for their child/youth or family member at any given point in time. May facilitate or assist with Family Advisory Committee.
Identify patient and family needs and unmet needs, strengths and assets. Assess biopsychosocial needs of at-risk patients, i.e., single parents, substance abuse, complex medical patients, etc. Promotes teams and actively participates in daily huddles. Organizes workshops/training for teams and patients.
Build care relationships among family and team; support the primary care-giving role of the family.
As a member of the care team, monitor patient care plans with family/youth/team (emergency plan, medical summary and action plan as appropriate). Carry out care plans, evaluate effectiveness, monitor in a timely way and effect changes as needed; use age appropriate transition timetables for interventions within care plans. Contacts identified patients for preventative services and/or pre-visit forms.
Case management coordination of services such as, transportation, referrals, post-hospitalization discharge; Makes follow up communication to patients/families on matters such as confirmation of delivery of equipment, emergency room visits, hospitalization, identified overdue labs/images,no show appointments, etc. in coordination with office clinical staff.
Coordinate inter-organizationally among family, the medical home, and involved agencies. Identifies community resources and tracks select community and specialty referrals.Connect to and understand community resources, i.e., WIC, food stamps, DME providers, advocacy groups, schools, financial assistance, counseling, anger management classes, special needs camps or inner-city camps. Refer patients to early intervention and public health nurses and help office staff and parents navigate through the school system and help with IEPs.
Collaborates with the practice on the NCQA process at the office working in close collaboration with the Medical Home liaison. Promotes/documents Quality Improvement Cycles.
Facilitate referral to behavioral health visits as needed. Coordinate with integrated psychology providers in the primary care practice. Work as part of the inter-disciplinary team of physicians, nursing, psychologist, and patient/family. Provide suicide risk assessment and safety planning or referral to community behavioral health providers/resources, as needed. Provide intervention and referral to community-based therapy or supportive resources for parents who screen positive for postpartum depression and/or anxiety.
Partner with providers in assessing for child maltreatment and neglect. Make referrals to child protective services agencies, as indicated.
Qualifications-
MSW Required
LMSW or LCSW Preferred
Experience with pediatric patient populations preferred.
Nemours is committed to improving the health of children. As a non-profit children’s health organization, we consider the health of every child to be a sacred trust. Through family-centered care in our children’s hospitals and clinics in Delaware, New Jersey, Pennsylvania and Florida, as well as world-changing research, education and advocacy, Nemours fulfills the promise of a healthier tomorrow for all children — even those who may never enter our doors. Nemours began more than 70 years ago with the vision of Alfred I. duPont to improve the lives of children and to do whatever it takes to prevent and treat even the most disabling childhood conditions. Today, through our children’s hospitals and health system, we directly care for 250,000 children annually in Delaware Valley and Florida, including families who travel from across the country and world to see our specialists — treating every child as we would our own. We also reach beyond the walls of our hospitals and clinics to be a voice for children on a national and international level, and to lead the way in prevention, intervention, education, and research. Nemours is growing to better serve the children and families in our ca...re. We have 1.1 million square feet of space currently devoted to providing children’s healthcare or under construction, all designed with significant input and advice from our patients and families.
