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Full/Part Time: Full Time
Location/Affiliates: Mount Sinai Medical Center (Manhattan)
Department: 186 - Social Services
Requisition Number: 14-1621002
The Mount Sinai Hospital Queens (MHQ) is a partner in Queens Community Care Partners (QCCP) which was selected by New York State Department of Health as a Queens Health Home (HH). The HH is designed to serve Medicaid FFS/Medicaid Managed Care enrollees who have high-cost and complex chronic conditions that drive a high volume of high cost inpatient episodes. Patient populations include (1) those living with HIV; (2) those living with chronic medical conditions; (3) those living with chronic and persistent mental illness. The HH, a patient-centered program, follows a care management service model which aims, through improved care coordination and service integration, to control future health care costs and improve health outcomes for this population. The goal of Health Home care management is to treat the whole patient, including medical care, behavioral health care, and community support services. Specifically, the patient population includes (1) those living with HIV; (2) those living with two or more chronic medical conditions; (3) those living with chronic and persistent mental illness.
The role of the Health Home social worker is to serve as a member of the interdisciplinary care teams of several Mount Sinai Queens outpatient practices, as well as the Emergency Department. The social worker will work closely with these teams and the high risk patients (identified either by the New York State Department of Health, or by the practitioners in the practices) to conduct care management and therefore assist in the achievement of the Health Home goals. The Health Home social worker will conduct biopsychosocial assessments with the patient and caregiver as needed, identify barriers to seeking appropriate medical care, and work with the team and patient/caregiver to develop a care plan. The goals of the care coordination interventions are to overcome these barriers and increase compliance (e.g., with appointments, medication regimen).
The Health Home social worker will communicate with external organizations in the community, as well as on-site providers to facilitate adherence to the care plan (e.g. transportation, legal, housing, appointment adherence). The Health Home social worker is also responsible for educating patients/family caregivers on how to navigate the health system, connecting them to resources, and empowering them to use these resources. The Health Home social worker will visit patients in their home or accompany patients to appointments as needed. The Health Home social worker, along with the care team, is responsible for referring high risk patients with continued health management issues to the high risk interdisciplinary team, which will discuss the case and explore other options. For common patients, the Health Home social worker communicates with care coordinators in other programs to ensure collaborative and streamlined work. The Health Home Social Worker will document in the Electronic Medical Record according to Health Home specifications and utilize other electronic systems to support the work.
New York State LMSW or LCSW required.
Exceptional skills in engaging patients and families and in assessment and coordination of resources within families and hospital and community networks for effective management of patient care.
Exceptional organizational, collaborative and psychosocial assessment and intervention skills.
Interest in being part of an innovative initiative to improve the quality of care by addressing barriers to primary and specialist care, preventable Emergency Department visits and hospital admissions/readmissions.
Hospital experience and experience with geriatric patients preferred.
Proficiency in MS Office: Word, Excel, Outlook. Ability to learn hospital ambulatory scheduling system, electronic medical record and specific care coordination applications.
Mount Sinai Medical Center is an equal opportunity/affirmative action employer. We recognize the power and importance of a diverse employee population and strongly encourage applicants with various experiences and backgrounds. Mount Sinai Medical Center--An EEO/AA-D/V Employer.