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Department of Social Services (MSH) - Req Number: 2510334
Job Title: Social Worker – Children’s Health Home
The Mount Sinai Health Home Serving Children (MSHH-C) forms an important component of the range of services provided through Mount Sinai Health Partners (MSHP). MSHP is the management services organization developed to enhance the Health System’s implementation of population health initiatives, that is, programs of care that enhance the patient experience and health status, improve the health of patient populations and reduce utilization and healthcare costs. Population health initiatives particularly focus on preventive care. MSHP provides the infrastructure to support population health initiatives and includes services such as care coordination, information technology, workflow optimization, physician engagement and quality reporting. The Department of Social Work Services takes a leadership role in MSHP Care Management, which is providing in person and telephonic short-term and long-term care management services for a large diverse group of individuals who have a variety of insurances that are part of value based contracts. The goal of MSHP Care Management is to provide standardized care management services to meet patients’ medical and psychosocial needs, increase quality and reduce unnecessary health care costs.
New York State has designated MSHH-C as a Manhattan Health Home serving the 0-21 year old population in the 5 boroughs. The Health Home is designed to serve Medicaid/Medicaid Managed Care enrollees who have high-cost, complex chronic conditions, and Severe Emotional Disturbance (SED) that drive a high volume of high cost 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 family and community support services. Specifically, the patient population includes (1) those living with HIV; (2) those living with two or more chronic medical conditions including the medically fragile; (3) those living with serious and persistent mental illness including SED; (4) those living in foster care; and (5) those exposed to trauma and at risk. The MSHH-C has expanded these services to include various pediatric practices and populations, e.g. GI, Cancer, and Neurology. The Social Worker provides psychosocial support to children and families in ambulatory programs.
The role of the Social Worker within the MSHH-C is to serve as a member of the interdisciplinary care team and to work closely with this team to provide complex care management services to patients at risk for avoidable hospital and emergency department utilization. The Social Worker conducts biopsychosocial assessments with patients and family caregivers, identify barriers to seeking medical/behavioral health care and work with the team and patient/family caregivers to develop a care plan to overcome these barriers and improve health outcomes. (S)he creates linkages for patients with community organizations to facilitate adherence to the care plan in the community. The Social Worker is responsible for educating patients/family caregivers on how to navigate the health system.
• New York State LMSW or LCSW.
• Bilingual (English/Spanish) preferred.
• Exceptional skills in engaging patients/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.
• Experience providing social work services to children and adolescents with chronic illness preferred.
• Experience in health care setting preferred.
Strength Through Diversity