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Full/Part Time: Full Time
Department: 186 - Social Services
Requisition Number: 14-1632956
New York State has designated the Mount Sinai Health Home as a Manhattan Health Home. The Health Home includes Beth Israel, St. Luke's, Roosevelt, Mount Sinai, and their associated ambulatory practices, as well as a network of 14 community-based organizations. The Health Home is designed to serve Medicaid/Medicaid Managed Care enrollees who have high-cost and complex chronic conditions that drive a high volume of high cost inpatient episodes. The Health Home, a patient-centered program, is 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. Throughout the Mount Sinai Health System, social workers within the adult primary care, HIV, addiction, and psychiatry practices are providing ongoing Health Home care management services to ensure that patients "receive everything necessary to stay healthy, out of the emergency room, and out of the hospital."
The role of the Health Home social worker is to serve as a member of the interdisciplinary care teams of several Mount Sinai Health System outpatient practices, as well as the Emergency Department and some inpatient units. 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 providers 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 (with appointments, medication regimen, etc.). The Health Home social worker will allow the Mount Sinai Health Home to assist patients who do not fall within the practices/departments where care management is currently provided.
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 MSHS 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 preferred.
Proficiency in MS Office: Word, Excel, Outlook. Ability to learn hospital ambulatory scheduling system, electronic medical record and specific care coordination applications.
Bilingual: English/Spanish preferred.
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.