Palliative LICSW

023540 Clin Alli-Palliative Care

Position Summary:
The Palliative Care Social Worker (Mobile) provides consultative specialty services related to serious illness impacts on members and caregivers and care coordination to a defined panel of CCA member’s needs. The panel of members will be comprised of individuals with serious illness and may have significant behavioral, psychosocial, and medical complexities that require intensive clinical support (in addition to that provided by the member’s primary care provider) that help decrease barriers to fully and successfully accessing the health care system. 

The Palliative Care Social Worker (Mobile) is the part of a team responsible for the clinical, behavioral health, and care coordination related to serious illness for their panel of members. Responsibilities include care coordination, behavioral health support, social support, liaison with other relevant providers around medical, chronic disease, behavioral health and long-term service and support needs, and the provision (with support) of end of life/palliative care, as needed. Role also includes a compendium of care coordination functions encompassing the development and implementation of the member-centered individualized care plan.

In addition to palliative care services, this position may provide comprehensive behavioral health care to complex patients in the Community Intensive Care Program.  Commonwealth Care Alliance’s (CCA) Community Intensive Care (CIC) programing is responsible for providing care delivery and care management to a specific panel of high risk and complex people.  This panel of CCA’s patients incorporates the care of individuals with significant medical, behavioral, and social complexities that require intensive care management and care delivery.

Supervision Exercised:
•    No, this position does not have direct reports.  

Essential Duties & Responsibilities:
•    Works collaboratively with other clinical leaders to design, implement, and refine the provision and integration of Palliative Care consultative services within the team model of care. 
•    Participates in the design, implementation, and performance of quality measurements and improvement activities relative to Palliative Care services.
•    Provides direct service including in-person and virtual visits for evaluation and short-term support to individuals and care givers in coordination with the primary care providers. 
•    Provides triage for patients with behavioral health and substance abuse issues, referring to appropriate inpatient or outpatient setting in collaboration with the primary care providers. 
•Monitors patient progress and assists the clinical team with evaluating the need for continued services. 
•    Initiates behavioral health treatment plans related to palliative care and coordinates services with community providers according to policy and procedure. 
•    Acts as a liaison to long terms care facilities, coordinating care and facilitating appropriate discharge and aftercare for members on Palliative Care at CCA. 
•    Participates in a variety of administrative functions as requested including network development, quality improvement programs and clinical guideline development. 
•    Provides support groups as care needs dictate. 
•    Participates in team meetings and provides input to clinical teams on Palliative care behavioral health issues, treatment options and strategies. 
•    Supports staff in dealing with their emotion in loss of a patient.
•    Attends educational and training activities that promote appropriate, safe, and effective care. 
•    Provides encouragement and guidance to patients and families to make arrangements in advance regarding the funeral, wills, requests, obituaries and interment
•    Facilitates and/or participates in member care conferences. 
•    Advocates for members in a culturally competent manner. 
•    Ensures members’ rights to fair and equitable treatment and self determination 
•    Participates in quality assessment and quality improvement within the scope of responsibilities as appropriate
•    Provides bereavement services, including phone calls, visits, and memorial services, to caregivers and staff upon the death of a patient
•    Shows an ongoing commitment to learning about the tenants of Palliative Care through ongoing pursuit of education 
•    These duties may include conducting urgent behavioral health visits to prevent emergency room utilization, performing post-hospital discharge psychiatric follow-ups, delivering long-term support for patients with severe persistent mental illness (SPMI), providing bridge therapy while awaiting network behavioral health referrals, and conducting substance use disorder assessments and treatment coordination. The role includes performing crisis assessments and interventions, developing crisis plans, conducting comprehensive behavioral health evaluations with appropriate diagnoses and treatment planning, and collaborating with interdisciplinary care teams and external providers to ensure comprehensive behavioral health integration within the patient's overall care plan. Documentation of all behavioral health interventions must be completed within established timelines while maintaining productivity standards through balanced routine and urgent patient encounters.

Working Conditions: 
•    This is member-facing position and requires travel and personal vehicle.
•    Valid driver’s license with no restrictions. Ability to be active and mobile across MA
Other: 
•    This position will utilize standard office equipment, including a Cell Phone.

•    Valid driver’s license with no restrictions. Ability to be active and mobile across MA.

Physical Requirements:
•    The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job
•    Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions
•    While performing the duties of this job, the employee is regularly required to stand; use hands to finger, handle, or feel; reach with hands and arms; and talk or hear
•    The employee is occasionally required to walk; sit; and stoop, kneel, crouch, or crawl
•    The employee must frequently lift and/or move up to 10 pounds and occasionally lift and/or move more than 100 pounds
•    Specific vision abilities required by this job include close vision, distance vision, and ability to adjust focus
 

Essential Duties & Responsibilities:

• Works collaboratively with other clinical leaders to design, implement, and refine the provision and integration of Palliative Care consultative services within the team model of care. 

• Participates in the design, implementation, and performance of quality measurements and improvement activities relative to Palliative Care services.

• Provides direct service including in-person and virtual visits for evaluation and short-term support to individuals and care givers in coordination with the primary care providers. 

• Provides triage for patients with behavioral health and substance abuse issues, referring to appropriate inpatient or outpatient setting in collaboration with the primary care providers. 

• Monitors patient progress and assists the clinical team with evaluating the need for continued services. 

• Initiates behavioral health treatment plans related to palliative care and coordinates services with community providers according to policy and procedure. 

• Acts as a liaison to long terms care facilities, coordinating care and facilitating appropriate discharge and aftercare for members on Palliative Care at CCA. 

• Participates in a variety of administrative functions as requested including network development, quality improvement programs and clinical guideline development. 

• Provides support groups as care needs dictate. 

• Participates in team meetings and provides input to clinical teams on Palliative care behavioral health issues, treatment options and strategies. 

• Supports staff in dealing with their emotion in loss of a patient.

• Attends educational and training activities that promote appropriate, safe, and effective care. 

• Provides encouragement and guidance to patients and families to make arrangements in advance regarding the funeral, wills, requests, obituaries and interment

• Facilitates and/or participates in member care conferences. 

• Advocates for members in a culturally competent manner. 

• Ensures members’ rights to fair and equitable treatment and self determination 

• Participates in quality assessment and quality improvement within the scope of responsibilities as appropriate

• Provides bereavement services, including phone calls, visits, and memorial services, to caregivers and staff upon the death of a patient

• Shows an ongoing commitment to learning about the tenants of Palliative Care through ongoing pursuit of education

• These duties may include conducting urgent behavioral health visits to prevent emergency room utilization, performing post-hospital discharge psychiatric follow-ups, delivering long-term support for patients with severe persistent mental illness (SPMI), providing bridge therapy while awaiting network behavioral health referrals, and conducting substance use disorder assessments and treatment coordination. The role includes performing crisis assessments and interventions, developing crisis plans, conducting comprehensive behavioral health evaluations with appropriate diagnoses and treatment planning, and collaborating with interdisciplinary care teams and external providers to ensure comprehensive behavioral health integration within the patient's overall care plan. Documentation of all behavioral health interventions must be completed within established timelines while maintaining productivity standards through balanced routine and urgent patient encounters.

Working Conditions:

• This is member-facing position and requires travel and personal vehicle.

• Valid driver’s license with no restrictions. Ability to be active and mobile across MA

Other:

• This position will utilize standard office equipment, including a Cell Phone.

• Valid driver’s license with no restrictions. Ability to be active and mobile across MA.

Physical Requirements:

• The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job

• Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions

• While performing the duties of this job, the employee is regularly required to stand; use hands to finger, handle, or feel; reach with hands and arms; and talk or hear

• The employee is occasionally required to walk; sit; and stoop, kneel, crouch, or crawl

• The employee must frequently lift and/or move up to 10 pounds and occasionally lift and/or move more than 100 pounds

• Specific vision abilities required by this job include close vision, distance vision, and ability to adjust focus

Required Education (must have):

• Master’s Degree in Social Work

• LCSW or LICSW (If LCSW must have LICSW within 12 months of hire date)

• Certified in Basic Life Support for Healthcare Providers 

MA Health Enrollment (required if licensed in Massachusetts):

Yes, this is required if the incumbent is licensed in Massachusetts. 

Required Experience (must have):

• 3+ years’ experience as LICSW, LCSW, PhD or Psy-D in a clinical setting. 

• Meaningful clinical experience in care management  

Desired Experience (nice to have):

• Past experience caring for patients/members facing end of life with complex medical, behavioral health, and social needs strongly preferred. 

• Hospice and Palliative certification

• Crisis experience, including telephonic, preferred.

Required Knowledge, Skills & Abilities (must have):

• Ability to use SBAR Communication 

• Ability to utilize an Electronic Medical Record 

• Demonstrated understanding of the benefits of each program; SCO and One Care 

• Ability to complete and update a Care Plan that meets CCA requirements 

• Demonstrated understanding of LTSS 

• Ability to initiate referrals to outside services as appropriate

• Ability to complete and lock all required documentation within 48 hours 
  Demonstrated knowledge and ability to use cognitive, depression and anxiety screening/ assessment tools (e.g., PHQ 2, PHQ 9, MMSE, MOCA)

• Demonstrated understanding of Referral to Specialists 

Required Language (must have):

• English