The Population Health Social Worker is responsible for acting as lead clinical staff for the Transitions of Care and Complex Care teams. The Population Health Social Worker will work along with the Population Health RN as clinical leads of the TOC team as they support LCHC patients who are hospitalized. This will include review of all cases at partner institutions, in-person contact at hospital, and delegation of responsibility to other TOC team members. It also will include significant phone contact with inpatient staff, community agencies and patients. The Population Health Social Worker will also use their clinical skills, advocacy and knowledge of community resources to effectively support patients in determining follow up for patients’ post-discharge to ensure best outcomes clinically for the patient. The Population Health Social Worker will also serve as a lead in providing and supporting ongoing follow up for LCHC’s most complex “high utilizer” subgroup of patients.
Principal Duties and Responsibilities*
1) Transitions of Care
A. Serve as clinical leader of TOC team- reviewing admissions whether at partner hospitals or other community institutions, taking lead on cases deemed to be best served by a SW, and providing support to other team members on cases not needing to be primarily managed by SW.
B. Provide effective mobile interventions where needed- at the hospital, in the clinic, at patients home or in the community
C. Outreach hospitals to work with CM and hospital teams to confirm status and plan for currently hospitalized folks at other hospitals
D. Accept requests for consult in on cases managed by RN or IPCC when needed for further medical support.
E. Review inpatient cases and hand off to non-clinical staff when appropriate
F. Complete all needed risk assessments, care planning and documentation needed for funders
G. Complete post-discharge phone or in-person contact with assigned cases and intervene where needed to ensure patient’s stability in community
H. Communicate with care team and PCP where needed to address patient’s care needs
I. Provide warm hand off back to care team CM to enable them to better support their assigned patients
2) Complex Care
A. Provide ongoing support to our group of most complex high utilizer patients through either direct care management or support to care team CM’s.
B. Provide persistent outreach and engagement to better support LCHC “high utilizers” in engaging well with LCHC.
C. Complete all needed tasks to ensure engagement and support for patient either in partnership with CM or directly including tasks outside of regular SW practice- referral support, DME + home health follow up, assistance with benefits etc.
· Motivational Interviewing- good understanding of stages of change
· Comfortable working with patients with severe mental illness and substance use disorder.
· Knowledgeable of harm reduction and comfortable engaging patients from that framework.
· Comfortable collaborating with multidisciplinary team regarding patients care needs in both inpatient and outpatient settings.
· Comfortable with providing clear and concise delegation to non-clinical TOC staff
· Flexibility to adapt to changing or stressful conditions, including unanticipated changes to workflows or processes.
· Good interpersonal skills including an ability to work well with the variety of ages, cultures, and temperaments represented among LCHC staff and patients, treating others with kindness and professionalism in all they do.
· Commitment to demonstrating personal integrity through punctuality, honesty, an ability to follow instructions, proper attention to detail in all work matters, and a willingness learn from others.
· Possesses the ability to work independently, take initiative, and set priorities in accordance with the needs and mission of the clinic.
· Demonstrates clear and concise written and verbal communication skills for communicating coherently and professionally with patients and co-workers.
· Conscientious of departmental and organizational policies and procedures, and able to embrace and personify the mission of the Lawndale Christian Health Center.
Internal Number: 8725883020
About Lawndale Christian Health Center
The mission of Lawndale Christian Health Center is to show and share the love of Jesus by promoting wellness and providing quality, affordable healthcare for Lawndale and the neighboring communities.
Our values are an extension of the Christian Community Development philosophy, embodied by the "3 R's": Relocation, Reconciliation, and Redistribution. Lawndale Christian Health Center was founded by Lawndale Community Church in 1984.
Lawndale Christian Health Center is recognized by the National Committee for Quality Assurance (NCQA) as a Patient Centered Medical Home (PCMH). PCMH is a model of health care that strengthens the relationship between providers and patients through long term care from one care team at one location led by a physician. As a PCMH, Lawndale Christian Health Center’s goal is to provide personalized and coordinated care that is high quality, affordable, and effective.
PCMH services provided by LCHC include same day, evening hours, and weekend appointments, preventive care, school physicals, an online patient portal, and self-care management.
Through our mission, LCHC is working to improve the health of the more than 60,000 patients who have chosen u...s as their medical home, as well as the health of our surrounding community.
For the 20-30% of our patients who have no insurance, LCHC is the place where quality health care is accessible. For community residents who are seeking jobs, LCHC is a place to secure employment. For students, LCHC is a place to receive training. For our peers, LCHC is a place to find ideas about providing healthcare for an underserved community. And for each of our patients and friends, we hope that LCHC is a place where they experience the love of Jesus Christ.
Lawndale Christian Health Center is accredited by the Joint Commission on Accreditation of Health Care Organizations (JCAHO), and is recognized as a Federally Qualified Heath Center (FQHC) by the U.S. Department of Health and Human Services' Bureau of Primary Health Care.