Role Description
The House Calls Behavioral Health Specialist is a key resource for the At-Home Care Teams. The At-Home Care Teams deliver high-touch, high-quality primary care to our Oak Street Health's highest risk patients. In this role, the LCSW will coordinate, support and perform community based, behavioral healthcare for these patients and will be a key contributor and collaborator within the care team to support care coordination and all other needs.
Core Responsibilities
Collaborate with OSH At-Home providers and Psychiatric Consult to identify and intervene with patients with psychosocial, community resource, and/or behavioral health needs
Function as the behavioral health and community resource expert on the OSH At-Home care team and actively contribute during team meetings
Facilitate goals of care and advance care planning discussions with patients and families in collaboration with their medical providers
Manage referrals for patients requiring specialized services through resource connections
Actively manage the shared BH registry to track individual patient progress of treatment toward target
Prepare and attend weekly registry review sessions with Psychiatric consult
Function as the behavioral health and community resource expert on the OSH At-Home care team and actively contribute during interdisciplinary team meetings
Screen and assess patients for common mental health and substance use disorders
Develop care plans and facilitate referrals to external resources
Provide short-term counseling and evidence-based treatments within the Collaborative Care Model
Accurate and timely documentation of patient encounters in Oak Street's electronic medical record
Other duties, as assigned
What are we looking for?
We're looking for motivated, licensed clinical social workers with:
Comfort and ability to work in a variety of environments, including patients' homes
Demonstrated ability to collaborate effectively in a team setting
Comfort supporting patients who are facing significant health, psychosocial and/or mental health issues
Experience with performing comprehensive biopsychosocial health, mental health and substance abuse disorder assessments
Experience with assessment and treatment planning for those with common mental health and/or substance use disorders and complex psychosocial needs
Working knowledge of differential diagnosis and psychosocial treatments of common mental health and/or substance use disorders
Familiarity with brief, structured intervention techniques (e.g., Motivational Interviewing, Behavioral Activation)
Proficient PC skills
US work authorization
Someone who embodies being 'Oaky'.
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