CATCH Social Worker, LICSW

Social Worker For CATCH Program

Responsible for providing individual and group clinical support and case management services for CATCH program patients. CATCH is Neighbor Health'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 Neighbor Health 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 Neighbor Health Behavioral Health Department activities that support clinical excellence.

Intake and enrollment of new participants

• Demonstrates knowledge of Neighbor Health CATCH program and is available as a resource to potential participants and family members.
• 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.
• 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 Mass Health'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…