POSITION SUMMARY

The Pediatric Primary Care Social Worker will assist in the employment of a proactive approach to provide care management for high-risk pediatric patients and family members/caregivers managing psychosocially complex conditions that may impede general medical care and health related outcomes. Provides a wide array of social work and care management services to pediatric patients and caregivers to promote understanding and resolution of problems related to environmental stress, physical illness, interpersonal conflicts, financial hardship, and other psychosocial issues.

ACCOUNTABILITIES

*All duties listed below are essential unless noted otherwise*

1. Uses a comprehensive risk stratification algorithm and pursuit lists delineating care gaps to identify high-risk patients that may benefit from care management services.

2. Works with the inter-professional team to provide care management support for patients identified as high-risk for poor outcomes secondary to behavioral health concerns and/or chronic health conditions.

3. Interviews pediatric patients, families, and/or caregivers to assess personal and social adjustment and determine necessary intervention(s) to mitigate risk.

4. Deliver interventions that will address barriers that pediatric patients’ mental, behavioral, or substance abuse disorders pose to the delivery of general primary care, including connectivity with appropriate resources.

5. Collaborate with pediatric multi-disciplinary team to implement treatment plan.

6. Prepare psychosocial assessment histories at the request of providers, and develop individualized therapy/counseling based on screening, assessment, and goals, establishing referral pathways as needed.

7. Documents in the medical record describing progress on case, including psychosocial assessment and interventions.

8. Refers patients and family members/caregivers to community agencies for counseling regarding interpersonal conflict, emotional problems, and chronic illness, as appropriate. Facilitates connectivity with needed services, as appropriate.

9. Participates in and facilitates team conferences, as appropriate, with pediatric patients, families, caregivers, and community service providers. Communicates with primary care providers and other caregivers to ensure care plan alignment and continuity of care.

10. Counsels pediatric patients and their families/caregivers to enhance their understanding and acceptance of personal and situational problems; helps them to change maladaptive patterns of behavior and to make decisions about problems resulting from chronic illness, disability, or end of life. Serves as support while providing crisis intervention.

11. Performs other duties as directed.