Transitional Housing Clinical Outreach Social Worker

The Clinical Outreach Social Worker (COSW) uses advanced clinical and/or healthcare operationalsubject matter expertise combined with systems and workflow knowledge to manage and assist incompassionate interventions to patients with complex psychosocial needs who discharge from OHSUEmergency Department and hospital. The COSW prioritizes clients with limited connections tooutpatient services and frequent ED encounters. This population is growing in numbers cost andcomplexity. This work requires unique skill set flexibility and vast network of community partners tobe able to effectively offer care. Job responsibilities include identifying enrollees conducting needsassessments identifying appropriate resources and facilitating service engagement via face-to-faceoutreach and phone contact. Assessments and services are offered in the ED hospital on the streetsand in homeless camps in patient homes outpatient clinics and other community settings. TheCOSW coordinates treatment efforts with other OHSU departments partners community partners

and affiliates to advocate for client needs. Interventions aim to reduce unnecessary hospital and EDvisits by improving access to medical care substance use disorder treatment mental health servicesand housing. While assisting clients in accessing services the COSW identifies client strengthsmodels problem-solving skills encourages mutual participation and enhances self-advocacy COSW participates in data collection for program evaluation purposes and partners with otherteam members to ensure effective implementation of services. The COSWs values and care delivery

are consistent with the NASW code of ethics.

Specialty Addendum for this Transitional Housing COSW position: The TH COSW will providespecific direct service supports to patients in both the inpatient units and in the community tofacilitate patients getting the appropriate level of care and resources. This Transitional Housing Clinical Outreach Social Worker will be supporting the Transitional care teams and TC motels and will including hospital in-reach and in person community based outreach supports. This position will take lead on inpatient social work discharge planning and outreach care coordination for patients identified as participants in one of the OHSU Care Management Transitional care service lines (motels RCP AFH ICF etc).

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.

Intensive Clinical Management

• Care planning:
  • COSW assesses patients for psychosocial andtransitional care needs and participates in developing patient-centeredcare plan. COSW assists patient in identifying goals and recognizingassociated behavioral modifications. COSW acts as a liaison betweenpatient and medical team when necessary and contributes clinicalexpertise to care plan offers recommendations for diagnosis andtreatment of mental health and addresses addictions issues whenappropriate. For patients without established primary care COSWfacilitates linkage to clinics that best meet patients needs.
  • COSW mayarrange appointments complete intake paperwork plan transportationoptions accompany client to appointments and support the patient andclinic staff during initial transition period. COSW often provide highlevel clinical care planning to outpatient community providers andsupport both the patient and the clinics while during this engagementperiod. COSW support prescribers with having detailed understandingof patients care needs and care needs outside of the clinic or hospitalsetting.
• Coordination of care:
  • COSW facilitates cross-site communicationbetween hospitals clinics and other community agencies. If patientreturns to ED/hospital SW serves as a source of knowledge about patients 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 partners 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.
• Clinical Practice:
  • Participation in standards development. Defined patient outcomes are achieved through provision of expert information recommendations and collaboration in care and clinical practice. Serves as a clinical consultant for OHSU physicians nursing staff RN CMs inpatient and clinic Social Workers and patients. Collaborates with patient/family and members of the multidisciplinary team in the development implementation and evaluation of a Patient Plan of Care. COSW streamline patient continuum of care transitions and logistical issues by provide liaison role between inpatient and outpatient providers. COSW provides education to patient/family in order to assist with patient-led discharge goals. Assesses patients SUD MH and physical healthcare treatment options as needed. Assesses patient/family understanding of ED/Inpatient admission Discharge Instructions and follow-up Care
• Interface with insurance companies:
  • COSW must be highly knowledgeable of insurance coverage needs requirements and processes. COSW must be able to independently facilitate prior authorizations and be able to provide clinical justification and documentation when needed.
  • The COSW work with highly complex patients often whose care needs and behavior are viewed as too complex for existing outpatient services/providers. COSW submits complex care need requests for flex funding with clinical rationale.
  • COSW are required to be able to navigate both the physical and behavioral-based insurance care needs. COSW are able to provide clinical interventions and recommendations for physical mental health substance use and housing-based services.
• Social Determinants of Health (SDOH):
  • COSW are content experts in identifying care planning and intervening to address the numerous disparities the target population faces with regards to SDOH.
  • COSW are able to assess and identify needs make referrals to services support engagement with referred services and provide feedback to the hospital leadership about care needs. Providing higher level teaching and mentorship on assessment and resources availability to hospital and community based social workers nurses and physicians.

• Masters in Social Work

• Current Oregon LCSW license required if Social Worker is hired.

• BLS required at time of hire issued by the American Heart Association (AHA) or Military Training Network branch of AHA

• 3 years work experience in healthcare disciplines including but not limited to care coordination case management community mental health chronic illness patient education and complex social issues; other relevant experience includes working with an adult under-servedpopulation and work in the Portland area safety-net.

• Must have familiarity with common outpatient medications and general medical knowledge.

• Valid OR/WA drivers license with an acceptable driving history and access to a car on a daily basis for home visits.

• LCSW preferred.
• 5 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 working within the Portland social service community and extensive knowledge of community resources.
• Experience conducting home visits and street outreach.
• Familiar with street safety assessment and crisis interventions and response.
• Post Graduate training and certification applicable to the job

• Requires prioritization..
• Frequent interruptions in an evironment 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.

Benefits:

• Healthcare Options - Covered 100% for full-time employees and 88% for dependents and $25K of term life insurance provided at no cost to the employee
  
• Two separate above market pension plans to choose from
  
• Vacation- up to 200 hours per year depending on length of service
  
• Sick Leave- up to 96 hours per year
  
• 8 paid holidays per year
  
• Substantial Tri-met and C-Tran discounts
  
• Additional Programs including: Tuition Reimbursement and Employee Assistance Program (EAP)