JOB PURPOSE AND REPORTING STRUCTURE: Under the direction of the Clinic Operations Director, the Clinical Social Worker facilitates smooth transitions for patients from hospital or specialty care settings back to outpatient primary care and behavioral health within a 48-hour time-frame. This position emphasizes a deep understanding and consideration of social determinants of health to address the holistic needs of patients.
 

ESSENTIAL DUTIES AND RESPONSIBILITIES include the following:

• Conduct comprehensive assessments of patients' social, emotional, economic, and environmental factors influencing their health.
• Identify and prioritize social determinants of health that may impact patients' ability to adhere to care plans.
• Understand how to access resources that meet the SDOH needs of all patients served.
• Collaborate with interdisciplinary and external teams, including physicians, nurses, therapists, care coordinators, case managers, social service agencies, as well as with county and states agencies to address social determinants of health.
• Assist in transitioning patients from hospital or specialty care settings to outpatient primary care within 48 hours of discharge.
• Assist in coordinating healthcare services, community resources, and support networks to enhance patient care.
• Provide counseling, support, and resources to patients and their families to address psychosocial and environmental factors affecting health.
• Advocate for patients to access community resources, financial assistance programs, housing support, and other social services.
• Educate patients and their families on the impact of social determinants of health on overall well-being and healthcare outcomes.
• Empower patients to advocate for themselves and actively participate in their care.
• Collaborate with crisis intervention teams, if necessary, to ensure the safety and well-being of patients.
• Maintain accurate and timely documentation of patient assessments, interventions, and outcomes.
• Assist with obtaining reports on the social determinants of health trends and their impact on patient care.
• Foster relationships with community organizations, social services agencies, and other stakeholders to enhance the availability of resources for patients.
• Participate in community outreach and awareness programs to address social determinants of health.
• Stay updated on the latest research, policies, and best practices related to social work in primary care transitions and social determinants of health.
• Attending relevant training and conferences to enhance skills and knowledge.
• Educate individuals and their families about the importance of advance directives.
• Provide information on different types of advance directives, such as living wills and durable power of attorney for healthcare.
• Evaluate the capacity of individuals to make informed decisions about advance directives.
• Assist individuals in completing and filing advance directive documents in accordance with state and federal regulations

EDUCATION and/or EXPERIENCE:

• Undergraduate degree in Social Work (BSW), Psychology, or Sociology.

• Preferred: Master’s degree in Social Work (MSW) from an accredited program, with housing and/or bilingual experience.

• State licensure or certification as a Social Worker and/or one to two years of related experience; or a combination of education and experience.

• Experience in healthcare, preferably in a primary care or transitions of care setting.

• Strong understanding of social determinants of health and their impact on patient outcomes.

• Excellent communication, collaboration, and advocacy skills.
  
   

  Outreach Community Health Centers, Inc. is an Equal Opportunity Employer