Social Worker; LCSW​/LICSW - Heart Transplant BWH

The Clinical Social Worker (LICSW) is a key member of the interdisciplinary team who provides and oversees the provision of psychosocial care for selected patients and families.

• Provides assessment of patients to evaluate mental health/psychiatric history/emotional issues/coping style, understanding of illness/adjustment/compliance, barriers to care, cultural issues, abuse/neglect and domestic violence.
• Provides psychosocial assessment of families to determine family relationships/systems as they relate to care of the patient. Identifies family decision makers and caregivers; family understanding of illness and trajectory of care. Identifies family coping style, family resources and cultural issues.
• Employs a range of clinical interventions such as individual, group or family counseling. Provides caregiver/family counseling/support to promote family cohesiveness to provide care to patient and prepare families for end of life. Advocates on behalf of patients and families to gain access to services and resources. Refers patients to other providers, as necessary.
• Develops comprehensive bio-psychosocial assessments responsive to age appropriate and cultural needs and concerns. Employs a range of clinical interventions such as psychotherapy (individual, couples, families, and group), psychosocial counseling, crisis intervention, care coordination, complementary therapies, information and referral and safety planning. Advocates on behalf of patients and families to gain access to services and resources.
• Provides mandated assessments when abuse is suspected (child, disabled adult, elder) and safety assessment when domestic violence is reported. Files reports as indicated.
• Identifies patients' psychosocial, financial, legal, psychiatric or substance use that affect patient care management and collaborates with the team to facilitate patient care process.
• Works effectively as part of the interdisciplinary health care team, communicating regularly with the team and other members on cases and as issues arise. Documents timely and relevant information.
• Coordinates family/team meetings, as needed and when appropriate. Provides psychosocial consultation on patient care planning and patient/family management and community resources. Implements psychosocial programs based on patient/family identified needs.
• Facilitates the appropriate and efficient use of hospital and community resources.
• Participates in formal and informal clinical case reviews, clinical supervision, educational seminars and research projects.

• Intervenes with appropriate individuals/departments/agencies regarding delays in service that may have an impact on quality of patient care, length of stay or inappropriate patient admissions.
• Reviews patient information for assigned caseload, determines anticipated length of stay and psychosocial barriers to plan of care transitions discharge plan in collaboration with the Nurse Care Coordinator.
• Interacts with home care, community agencies and facilities to ensure safe and timely patient care transitions.
• Negotiates with care coordination team follow up contact with patient/family, community agency or facility to evaluate the effectiveness of the patient care transitions and identifies problems in service delivery.
• Ensures coordination of the communication process with patient/family concerning the plan of care, including coordination of family meetings and warm handoffs.
• Ensures that patient/family is involved in all phases of the care process to the greatest extent possible.
• Maintains current knowledge of and identifies needs in service delivery within social, governmental, protective services and legal agencies.
• Participates in data collection for departmental quality assessment activities in collaboration with the care coordination department.
• Participates in quality assessment/improvement activities designed to evaluate the appropriateness and effectiveness of the service delivery system in which care coordination operates.
• Ensures that the patient and family receive consistent information regarding…