Clinical Outreach Social Worker, CTrain

The Clinical Outreach Social Worker (COSW) uses advanced clinical and/or healthcare operational subject matter expertise combined with systems and workflow knowledge to manage and assist in compassionate interventions to patients with complex psychosocial needs who discharge from OHSU Emergency Department and hospital. The COSW prioritizes clients with limited connections to outpatient services and frequent ED encounters. This population is growing in numbers, cost and complexity. This work requires unique skill set, flexibility and vast network of community partners to be able to effectively offer care. Job responsibilities include identifying enrollees, conducting needs assessments, identifying appropriate resources, and facilitating service engagement via face-to-face outreach and phone contact. Assessments and services are offered in the ED, hospital, on the streets and in homeless camps, in patient homes, outpatient clinics, and other community settings. The COSW coordinates treatment efforts with other OHSU departments, partners, community partners and affiliates to advocate for client needs.  Interventions aim to reduce unnecessary hospital and ED visits by improving access to medical care, substance use disorder treatment, mental health services and housing. While assisting clients in accessing services, the COSW identifies client strengths, models problem-solving skills, encourages mutual participation, and enhances self-advocacy abilities. The COSW participates in data collection for program evaluation purposes and partners with other team members to ensure effective implementation of services. The COSW’s values and care delivery are consistent with the NASW code of ethics.

 

This position is a flexible work position, which allows some remote work. Remote work at OHSU is a work arrangement under which an employee performs the duties and responsibilities of their position, and other authorized activities, from a non-OHSU location as part of their approved, regular work schedule. The Social Worker generally is expected to be in person at least half of their work time, depending on the expectations of their specific position. The social worker should have a private space at home, dedicated to work, and no Protected Health Information should be printed. Social Workers are expected to see patients in person, when at all possible, which may require coming to the hospital at short notice on a remote day.

• Care planning: COSW assesses patients for psychosocial and transitional care needs and participates in developing patient-centered care plan. COSW assists patient in identifying goals and recognizing associated behavioral modifications. COSW acts as a liaison between patient and medical team when necessary and contributes clinical expertise to care plan, offers recommendations for diagnosis and treatment of mental health and addresses addictions issues when appropriate. For patients without established primary care, COSW facilitates linkage to clinics that best meet patient’s needs.  COSW may arrange appointments, complete intake paperwork, plan transportation options, accompany client to appointments, and support the patient and clinic staff during initial transition period. COSW often provide high level clinical care planning to outpatient community providers, and support both the patient and the clinics while during this engagement period.  COSW support prescribers with having detailed understanding of patient’s care needs and care needs outside of the clinic or hospital setting.
• Coordination of care: COSW facilitates cross-site communication between hospitals, clinics, and other community agencies.  If patient returns to ED/hospital, SW serves as a source of knowledge about patient’s goals, care trajectory, post-discharge needs, and barriers to outpatient care. COSW acts as a point of consistency between systems to improve patient experience. COSW are required to be effective in working within the outpatient, inpatient, emergency department and other crisis based services.  COSW composes and/or updates EDIE care guidelines to increase cross-system knowledge of care plan. COSW often are asked to be content experts and lead facilitator for community-based care conferences with multidisciplinary providers and organizations. COSW are asked to provide other professionals with clinical background and recommendations on how to proceed with a highly complex and traumatized patient.
• Strategic Partner Facilitation: Facilitates integration of OHSU partners into OHSU Care Model. Seeks to understand our community and hospital partner’s clinical objectives and operating challenges and works to maximize their performance and resolve problems. Creates a clinical partnership that aligns objectives and optimizes performance for both OHSU and partners
• Clinical services: COSW offers clinical expertise to medical providers when relevant to drive effective diagnosis and treatment of mental health, substance use disorders, and to provide basic medical care to those experiencing homelessness. COSW are considered to be specialists in providing care to this vulnerable population. COSW provides intensive outreach and engagement to access needed community services, providing education, counseling and motivational interviewing to enhance outcomes of recommended supports and interventions. COSW builds rapport with the patient, modeling patient, modeling empathy and unconditional positive regard. Use of therapeutic techniques, by creating mutually agreed upon goals, help the patient enhance physical, psychological and social functioning. COSW practice interpersonal communication and system navigation skills alongside the patient. S/he provides positive reinforcement for behavioral modifications. COSW have a unique role when providing longitudinal care to those requiring palliative care and hospice based services.
• Case management: Assists patients in securing services to stabilize housing, obtain employment, access financial entitlements, treat addictions issues, and meet basic physical needs. Performs outreach by phone and in person to connect patient to services and increase participation in care. COSW maintains state of the art knowledge of social services in the Tri-County area, including but not limited to shelter access, medical insurance, housing resources, MAT programs, and specific mental health treatment options. COSW makes relevant referrals, advocates for services, and participates in systems-level decision-making when possible.

• Continuing education: COSW maintains active clinical licensure and obtains required CEUs. COSW participates in continuing education as a learner but also accepts opportunities to provide cross-disciplinary education via rounds, committees, conferences, and presentations when relevant opportunities arise
• Patient, Family and Provider Education: COSW provide psychoeducation to patients and/or their families, and providers that we directly work with. Collaborates with members of the interdisciplinary team including physicians, clinic and hospital personnel to be able to accurately understand care needs of our patients and to be effective in communicating with patients and supports. COSW often acts as an intermediary liaison between providers and patients to find shared goals and recommendations.  Provides patient/family with resource contact information as needed, and supports efforts to access and engage in these services. COSW offer coaching, mentoring, training to medical, nursing and social worker students, as well as to fellow colleagues and peers at OHSU. This training is focused on resources availability but also in clinical delivery of care with population with complex care needs.

• A Master’s Social Work (MSW) required.  Health care experience preferred.
• Certificate of Clinical Social Work Associate (CSWA) or Licensed Clinical Social Worker (LCSW) required for employees who practice clinical social work.

• 3+ years of professional experience diagnosing, treating and advocating for adults with mental illness and co-occurring substance abuse disorders in medical or community mental health settings.

• Experience conducting home visits and street outreach.
• Experience working within the Portland social service community and extensive knowledge of community resources. 
• Familiar with street safety assessment and crisis interventions and response
• Post Graduate training and certification applicable to the job
• Must be able to perform the essential functions of the position with or without accommodation

Requires prioritization.

Frequent interruptions in an environment of frequent change and fluctuations.

For inpatient units accepts accountability and responsibility.

May be exposed to body fluids, tissue, possible radiation exposure, and infectious processes.

Subject to computer work for several hours, as needed.

Able to utilize office equipment within work area.

 

 

We are Oregon's only public academic health center. In addition to caring for patients, we lead groundbreaking research. We also train the next generation of health care professionals. As Portland's largest employer, we give you opportunities to learn and advance in a system of hospitals and clinics across Oregon and Southwest Washington. All are welcome. OHSU welcomes people of all ages, ethnicities, genders, national origins, religions and sexual orientations. We are striving to build an anti-racist, multicultural institution and encourage people with diverse backgrounds to apply. To request reasonable accommodation, contact askhr@ohsu.edu