Overview

The Social Worker (SW) is a core member of the integrated behavioral health care team, along with the patient’s medical provider, psychiatric consultant, and patient. The SW is responsible for supporting and coordinating the mental and physical health care of patients on an assigned patient caseload. The SW facilitates ongoing communication with patients’ referring medical provider, as well as any other pertinent treatment providers, to ensure optimum level of care of patients. A SW effectively engages patients in brief therapeutic interventions while using evidence-based tools to assess progress. The SW communicates patient progress to the entire care team and adjusts treatment plans in collaboration with all members of the care team. Outside referrals are facilitated by the SW when patient requires alternate or higher level of care. The SW is responsible for maintaining data entry to monitor individual treatment progress, as well as overall program effectiveness.

1. Support the mental and physical health care of patients on an assigned patient caseload. Closely coordinate care with the patient’s medical provider and, when appropriate, other mental health providers.

2. Screen and assess patients for common mental health and substance abuse disorders. Facilitate patient engagement and follow-up care.

3. Provide patient education about common mental health and substance abuse disorders and the available treatment options.

4. Systematically track treatment response and monitor patients (in person or by telephone) for changes in clinical symptoms and treatment side effects or complications.

5. Support psychotropic medication management as prescribed by medical providers, focusing on treatment adherence monitoring, side effects, and effectiveness of treatment.

6. Provide brief behavioral interventions using evidence-based techniques such as behavioral activation, problem-solving treatment, motivational interviewing, or other treatments as appropriate.

7. Provide or facilitate in-clinic or outside referrals to evidence-based psychosocial treatments (e.g. problem-solving treatment or behavioral activation) as clinically indicated.

8. Participate in regularly scheduled (usually weekly) caseload consultation with the psychiatric consultant and communicate resulting treatment recommendations to the patient’s medical provider. Consultations will focus on patients new to the caseload and those who are not improving as expected under the current treatment plan. Case reviews may be conducted by telephone, video, or in person.

9. Track patient follow up and clinical outcomes using a registry. Document in-person and telephone encounters in the registry and use the system to identify and re-engage patients.

10. Document patient progress and treatment recommendations in EHR and other required systems so as to be shared with medical providers, psychiatric consultant, and other treating providers.

11. Facilitate 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.

12. Facilitate 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).

13. Develop and complete relapse prevention self-management plan with patients who have achieved their treatment goals and are soon to be discharged from the caseload.