CATCH Social Worker, LICSW

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• Time Type: Full time Department: Pediatrics All Locations: 10 Gove Street – Taylor Building

Position Summary

Responsible for providing individual and group clinical support and case management services for CATCH program patients. CATCH is NeighborHealth’s care coordination program for medically complex children. The CATCH Social Worker (SW) is an integral member of CATCH team. In this capacity, the SW conducts clinical assessments, formulates treatment plans which are updated in the medical record; coordinates interventions with other providers and members of CATCH team to support participants’ mental health consistent with NeighborHealth policies and procedures. CATCH SW reports directly to the Director of Pediatric Complex Care with clinical oversight by Behavioral Health Department Leadership. CATCH SW participates in NeighborHealth Behavioral Health Department activities that support clinical excellence. What You'll Do Intake and enrollment of new participants Demonstrates knowledge of NeighborHealth CATCH program and is available as a resource to potential participants and family members. Measured through clinical supervision. Able to administer a complete family centered psychosocial assessment and identify factors that impact upon the participant’s current level of functioning. Completes initial assessments and contributes to the plan of care by assisting the patient and family to articulate their care priorities and goals for the patient. Articulates partnership between CATCH, participant and family. Ability to address the families’ role in care for person with disability. Responds appropriately and initiates access to the utilization of concrete services i.e. SSI, housing, food stamps, money management etc. Case Management Serves the role of participant and family advocate by clarifying and representing the participant’s voice and perspective to the team and other community providers. Evidenced by active participation in all clinical meetings. Coordinates, and demonstrates a leadership role in family meetings evidenced by the ability to restate important themes and articulate conclusions or next steps. Shows flexibility in scheduling, modality and setting when performing initial and periodic assessments. Evidenced through use of home visits when indicated. Provides education to patient and family about their rights as patients, navigating health care systems, and empowers patients and families as self advocates. Initiates and refers participants and families to appropriate community agencies. Demonstrates an understanding and ability to utilize outside resources. Participates in MassHealth’s CARES (Coordinating Aligned, Relationship-centered, Enhanced Support) program enrollment process, identifies goals of care and participates in CARES team meetings. Coordinates transition from pediatric to adult primary care for patients as they age out of CATCH. Supports families and patients through transition to adult care and refers patients to appropriate community resources. Supports families through guardianship process, including explanation of guardianship, patient assessment, completing applications, communicating with other providers, schools, and psychologists to complete guardianship documents. Coordinates and assists patients with transition from Early Intervention (EI) to public school, guiding families through school registration and special education evaluations. Communicates with EI and school staff. Annual outreach to patients ages 2-4 who are eligible for school evaluations, and ages 17-18 who may need guardianship. Leads parent and patient advisory council, coordinates meetings, and parent/patient engagement opportunities. Address behavioral health needs of CATCH patients. Ability to provide psychotherapy, family therapy, supportive counseling, and psycho-education to participants and their caregivers. Demonstrates an ability to conduct and present findings in the use of assessment tools. Facilitates groups, for example: parents of newly diagnosed patients with ASD (autism spectrum disorder), transition planning for teens and young adults, grief counseling and support for siblings of children with special needs, and financial and social stressors imposed by increased supervision/care requirements. Assessment and treatment of behavioral/mental health disorders among family members of affected individuals, enhanced family function to prevent the development of secondary behavioral health problems, and address disorder specific issues seen in: survivors of extreme prematurity, Down syndrome, cerebral palsy syndromes, and autism, etc. Responsible for maintenance of appropriate records and documentation in accordance with departmental standards. Demonstrates fluency in the use of the electronic medical record. Progress notes in the record are comprehensive and kept current. Annual and periodic assessments are completed and documented in the medical record. Ability to write progress note in S.O.A.P. format. Participates actively as part of CATCH team. Participates in CATCH team meetings. Takes part in CATCH team initial and periodic assessments. Writes and follows up on stated treatment interventions. Supports and consults with CATCH team related to guardianship process, and is available to guide care navigators and NH behavioral health clinicians with guardianship (after achieving competence and experience). Completes guardianship assessment and paperwork. Shows an ability to assist families in palliative and end-of-life care through supportive counseling, psycho-education. Demonstrated through continuing education in end-of-life issues. Ability to participate and coordinate a discussion regarding advance directives, health care proxies, and end of life issues with the participant and their caregivers. Evidenced by providing family with literature and resources in end of life issues. Provides consultation to members of CATCH team to enhance their understanding of the psychological aspects of care. Knowledge demonstrated during CATCH team meetings. Encourages effective relationships among staff geared toward building and maintaining a cohesive team. Collaborates and communicates with specialists, behavioral health, and educators as needed. Assumes a range of professional responsibilities. Demonstrates ability to perform crisis intervention. Develops and leads activities, which demonstrate an area of clinical expertise. This may include but not be limited to group counseling, resource management. Comes prepared to present cases at individual and group supervision sessions. Shows an engagement in learning new skills and developing competencies. Demonstrates commitment to a holistic approach to care by actively engaging in CATCH planning and communication processes. Demonstrates the ability to communicate effectively and respectfully through verbal and written skills. Documents in accordance with protocol. Promotes a sense of teamwork through demonstration of self-direction and self-motivation. Solves problems independently or knows when to seek consultation. Provides leadership to other support staff on the practice team. Works cooperatively and respectfully with others at all levels of the organization. Interacts with patients in a professional and respectful manner, which reflects the needs and concerns of the individual. Maintains a positive attitude. Responsible for continued professional growth and development. Other Duties: Please note, this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities, and activities may change at any time with or without notice. What You’ll Bring: EDUCATION: Possess licensure as a Licensed Independent Clinical Social Worker (LICSW) only, preferably in a community setting. EXPERIENCE: Experience and/or interest in working with pediatrics, families, and individuals with disabilities and chronic illness, preferably in an interdisciplinary team setting. SKILLS/ABILITIES: Flexibility, initiative, creativity and organizational skills. The ability and willingness to assist outside of traditional roles. Bilingual English Spanish preferred.