Welcome to the Beth Israel Lahey Health Performance Network (BILHPN). BILHPN is a clinically integrated network of physicians, clinicians, and hospitals committed to providing high-quality, cost-effective care to the patients and communities they serve, while effectively managing medical expense. Leveraging best practices in population health management and data analytics, BILHPN improves care quality and patient health outcomes across Beth Israel Lahey Health through population health initiatives. BILHPN brings together the expertise of more than 4,500 providers across Eastern Massachusetts who share a common goal to achieve success in a value-based delivery system.
About the Job
As a Social Worker within Beth Israel Lahey Health Performance Network, you will have the opportunity to make a profound impact on the lives of people living with multiple chronic illnesses as well as vulnerable populations with complex medical, social, and behavioral health needs.
This position is responsible for supporting Beth Israel Lahey Health Performance Network ‘s (BILHPN) value-based care initiatives within risk contracts and will primarily be working within a Medicare ACO and collaboratively with primary care, ambulatory, and post-acute settings. The overarching goal is to improve the coordination of patient care, reducing total medical expenses over time. Your work will be to actively manage a panel of risk patients using medical management techniques to reduce hospitalization, readmission, and emergency department utilization. Consistent with the Triple Aim, The Social Worker seeks to enhance the quality and patient experience of care while eliminating unnecessary costs for patients. The Social Worker ensures that the patient obtains the best and most appropriate treatment by encouraging the most effective and cost-efficient use of health care and related services.
The Social Worker develops and maintains a therapeutic relationship with the patient, which may include linking the patient with systems that provide him or her with needed services, resources, and opportunities. The Social Worker provides care coordination for a patient's care throughout the care continuum including hospital stay, post-acute care delivered within subacute (skilled nursing facilities), and home settings. Connecting the patient and family to appropriate community services where needed to meet specific needs.
Working with the ACO team, the Social Worker monitors appropriate utilization of healthcare resources and promotes quality and efficiency by developing and implementing a patient-centered care plan. The Social Worker is accountable for ensuring efficient and professional social work services for patients and families that are designed to promote and enhance their medical, physical and psychosocial functioning with attention to the social and emotional impact of illness and disability.
The Social Worker upholds the current standards of social work case management practice and reports to the Manager of Care Management, Medicare Shared Savings Program-ACO.
- Accountable for providing safe patient care by demonstrating organizational skills that maintain and coordinate safe delivery of quality care for assigned patients/families.
- Develops a culturally competent plan of care that identifies patient problems, expected outcomes, and addresses preventative measures.
- Aims to improve patient’s overall quality of life within the community by supporting treatment goals, empowering them to be advocates for themselves, and assisting them to obtain benefits, access to health car,e and social services.
- Provides care coordination for individuals with multiple social stressors and/or behavioral health concerns. Utilizes screening criteria developed for the overall purpose of coordination of quality health care services, reduction of service fragmentation, enhancement of quality of life, and the appropriate use of health care resources.
- Engage patients and caregivers telephonically and in-person in active care planning to focus on social, financial, behavioral, and environmental needs of patients or identified gaps in care as identified through risk stratification, provider referrals or through standardized transition workflows.
- Assess social determinants of health, social service, and psychosocial needs.
- Develop and implement treatment plans including referral to programs and agencies and monitoring of services. Provide outreach, motivational interviewing and goal setting, and resource connection to help patients appropriately utilize healthcare.
- Develops and maintains strong working knowledge of insurance coverage benefits and policies to facilitate the provision of social service and behavioral health benefits.
- Maintain thorough working knowledge of public and private community-based agencies and services including eligibility and access requirements. Establishes and maintains a working relationship with agency staff to facilitate access and coordinate service.
- Follow-up with patients with positive responses to social determinant care gap screenings.
- Assists patients and caregivers in addressing and overcoming barriers with a range of concrete supports.
- Support and encourage patient engagement in behavioral health treatment options including connecting patients to local BH providers.
- Assists in obtaining advanced care directives, including facilitating serious illness conversations
- Assists in facilitating access to healthcare, including by arranging access to social services such as arranging transportation to medical appointments.
- Works independently providing case management services based on a comprehensive psychosocial assessment including addressing cognitive functioning, functional status, culturally sensitive issues, patient/caregiver support system, insurance, financial status and home & community environment. Uses this information to develop a patient-centered care plan and shares this information with patient/caregiver and healthcare team.
- Conducts reassessments on an ongoing basis, including at prescribed intervals and whenever there is a significant change in the patient’s health, abilities, living situation, and family involvement.
- Collaborates with the patient/caregiver and healthcare provider to formulate an individualized effective case management plan of care and implementation strategy, including by identifying the patient’s strengths and support systems.
- Participates in quality improvement activities aimed to improve patient-population outcomes and associated processes.
- Offers community-based care coordination for individuals in need of support and outreach in order to successfully engage medical, behavioral health and social services in the community.
- Works closely with nurse case managers, pharmacists, community health workers, and other members of the care team throughout the continuum of care including acute hospital, skilled nursing facility, acute rehabilitation, and home care. The Social Worker will be responsible for insuring the transitions of care are handled well and the needs of the patient/caregiver are anticipated and met.
- Makes referrals as needed to appropriate medical/psychology/behavioral health professionals and to appropriate community programs/resources.
- LICSW preferred, Masters in Social Work with at least 5 years' experience.
- 5 years medical or community based social work experience is preferred, working with adult/geriatric population
Full Tme, 40 hrs/wk, hybrid or remote work option available;
Beth Israel Lahey Health is dedicated to improving health and wellness and making a difference in the lives of our patients, their families and all members of the communities we serve. Formed in March 2019, Beth Israel Lahey Health is a patient-centered, integrated care delivery system providing a continuum of services spanning academic, tertiary and community hospitals, dedicated orthopedic and psychiatric hospitals, primary and specialty care, community acute care, ambulatory care, behavioral services and home health. Beth Israel Lahey Health Performance Network is a unified joint contracting and population health management organization, jointly governed by participating physicians and hospitals.
Equal Opportunity Employer/Minorities/Females/Disabled/Veterans.