Intensive Clinical Management

• Care planning:
  • COSW assesses patients for psychosocial and transitional care needs and participates in developing patient-centered care plan. COSW assists patient in identifying goals and recognizing associated behavioral modifications. COSW acts as a liaison between patient and medical team when necessary and contributes clinical expertise to care plan, offers recommendations for diagnosis and treatment of mental health and addresses addictions issues when appropriate. For patients without established primary care, COSW facilitates linkage to clinics that best meet patient’s needs.
  • COSW may arrange appointments, complete intake paperwork, plan transportation options, accompany client to appointments, and support the patient and clinic staff during initial transition period. COSW often provide high level clinical care planning to outpatient community providers, and support both the patient and the clinics while during this engagement period. COSW support prescribers with having detailed understanding of patient’s care needs and care needs outside of the clinic or hospital setting.
• Coordination of care:
  • COSW facilitates cross-site communication between hospitals, clinics, and other community agencies. If patient returns to ED/hospital, SW serves as a source of knowledge about patient’s goals, care trajectory, post-discharge needs, and barriers to outpatient care.
  • COSW acts as a point of consistency between systems to improve patient experience. COSW are required to be effective in working within the outpatient, inpatient, emergency department and other crisis based services.
  • COSW composes and/or updates EDIE care guidelines to increase cross-system knowledge of care plan. COSW often are asked to be content experts and lead facilitator for community-based care conferences with multidisciplinary providers and organizations.
  • COSW are asked to provide other professionals with clinical background and recommendations on how to proceed with a highly complex and traumatized patient.
• Strategic Partner Facilitation:
  • Facilitates integration of OHSU partners into OHSU Care Model. Seeks to understand our community and hospital partner’s clinical objectives and operating challenges and works to maximize their performance and resolve problems. Creates a clinical partnership that aligns objectives and optimizes performance for both OHSU and partners
• Clinical services:
  • COSW offers clinical expertise to medical providers when relevant to drive effective diagnosis and treatment of mental health, substance use disorders, and to provide basic medical care to those experiencing homelessness. COSW are considered to be specialists in providing care to this vulnerable population.
  • COSW provides intensive outreach and engagement to access needed community services, providing education, counseling and motivational interviewing to enhance outcomes of recommended supports and interventions. COSW builds rapport with the patient, modeling patient, modeling empathy and unconditional positive regard.
  • Use of therapeutic techniques, by creating mutually agreed upon goals, help the patient enhance physical, psychological and social functioning. COSW practice interpersonal communication and system navigation skills alongside the patient. S/he provides positive reinforcement for behavioral modifications. COSW have a unique role when providing longitudinal care to those requiring palliative care and hospice based services.
• Case management:
  • Assists patients in securing services to stabilize housing, obtain employment, access financial entitlements, treat addictions issues, and meet basic physical needs. Performs outreach by phone and in person to connect patient to services and increase participation in care.
  • COSW maintains state of the art knowledge of social services in the Tri-County area, including but not limited to shelter access, medical insurance, housing resources, MAT programs, and specific mental health treatment options. COSW makes relevant referrals, advocates for services, and participates in systems-level decision-making when possible.
• Clinical Practice:
  • Participation in standards development. Defined patient outcomes are achieved through provision of expert information, recommendations and collaboration in care and clinical practice. Serves as a clinical consultant for OHSU physicians, nursing staff, RN CMs, inpatient and clinic Social Workers and patients. Collaborates with patient/family and members of the multidisciplinary team in the development, implementation and evaluation of a Patient Plan of Care. COSW streamline patient continuum of care transitions and logistical issues, by provide liaison role between inpatient and outpatient providers. COSW provides education to patient/family in order to assist with patient-led discharge goals. Assesses patients’ SUD, MH and physical healthcare treatment options, as needed. Assesses patient/family understanding of ED/Inpatient admission Discharge Instructions and follow-up Care
• Interface with insurance companies:
  • COSW must be highly knowledgeable of insurance coverage needs, requirements and processes. COSW must be able to independently facilitate prior authorizations and be able to provide clinical justification and documentation when needed.
  • The COSW work with highly complex patients, often whose care needs and behavior are viewed as too complex for existing outpatient services/providers. COSW submits complex care need requests for flex funding with clinical rationale.
  • COSW are required to be able to navigate both the physical and behavioral-based insurance care needs. COSW are able to provide clinical interventions and recommendations for physical, mental health, substance use, and housing-based services.
• Social Determinants of Health (SDOH):
  • COSW are content experts in identifying, care planning and intervening to address the numerous disparities the target population faces with regards to SDOH.
  • COSW are able to assess and identify needs, make referrals to services, support engagement with referred services and provide feedback to the hospital leadership about care needs. Providing higher level teaching and mentorship on assessment and resources availability to hospital and community based social workers, nurses and physicians.

• LCSW preferred.
• 5+ years of professional experience diagnosing, treating and advocating for adults with mental illness and co-occurring substance abuse disorders in medical or community mental health settings.
• Experience working within the Portland social service community and extensive knowledge of community resources.
• Experience conducting home visits and street outreach.
• Familiar with street safety assessment and crisis interventions and response.
• Post Graduate training and certification applicable to the job