The Social Work Care Coordinator (MSW) will coordinate team-based care to provide health services and education to patients and families through effective partnerships with Delaware Children Health Network (DCHN) practices, community resources and medical professionals. Provides Care Coordination in the DCHN practice setting by utilizing critical thinking skills and social worker expertise in order to optimize patient outcomes amongst designated populations within the practice.

Works with patients and families to ensure both behavioral and psychosocial needs are met. Works with DCHN practices to address gaps in care and promotes timely access to appropriate care, increasing the utilization of preventative care and healthy behaviors to improve the health of the population at risk. Addresses gaps in care and promotes timely access to appropriate care, increasing the utilization of preventative care and healthy behaviors to improve the health of the population at risk. This position will be based the North Wilmington area.

Primary Responsibilities:

1. Assist with or promote the identification of patients in the practice with special health care needs; add them to the registry and use the registry to plan and monitor care. Monitors chronic/preventive patient registries/lists.
2. Initiate family contacts; create ongoing processes for families to determine and request the level of care-coordination support they desire for their child/youth or family member at any given point in time. May facilitate or assist with Family Advisory Committee.
3. Identify patient and family needs and unmet needs, strengths, and assets. Assess biopsychosocial needs of at-risk patients, i.e., single parents, substance abuse, complex medical patients, etc. Promotes teams and actively participates in daily huddles. Organizes workshops/training for teams and patients.
4. Build care relationships among family and team; support the primary care-giving role of the family.
5. As a member of the care team, monitor patient care plans with family/youth/team (emergency plan, medical summary and action plan as appropriate). Carry out care plans, evaluate effectiveness, monitor in a timely way and effect changes as needed; use age appropriate transition timetables for interventions within care plans. Contacts identified patients for preventative services and/or pre-visit forms.
6. Case coordination of services such as, transportation, referrals, connection to health care system; Makes follow up communication to patients/families on matters such as confirmation of delivery of equipment, emergency room visits, hospitalization, identified overdue labs/images, no show appointments, etc. in coordination with office clinical staff.
7. Serve as contact point, advocate and informational resource for family and community partners/payors. Referrals to child protective services and appropriate agencies for domestic violence. Completes forms such as DFS, FMLA, SSI, etc. and writes letters for housing, nursing care, medical necessity, etc.; Research, find and link resources, services, and supports with/for the patient/family. Arranges for supplies and equipment. Assists with getting insurance coverage for patients without insurance.
8. Coordinate inter-organizationally among family, the medical home, and involved agencies. Identifies community resources and tracks select community and specialty referrals. Connect to and understand community resources, i.e., WIC, food stamps, DME providers, advocacy groups, schools, financial assistance, counseling, anger management classes, special needs camps or inner-city camps. Refer patients to early intervention and public health nurses and help office staff and parents navigate through the school system and help with IEPs.
9. Partners with practice to close gaps in care, assist with hard to reach patients.
10. Facilitate referral to behavioral health visits as needed.

Performance Skills:

1. Relevant experience, or the equivalent, in community based pediatrics, home health care or primary care, particularly in the care and service of vulnerable populations such as children/youth with special health care needs (CYSHCN).
2. Leadership, advocacy, communication, education and counseling, and resource research skills.
3. Core philosophy or values consistent with a family-centered approach to care.
4. Culturally effective capabilities demonstrating a sensitivity and responsiveness to varying cultural characteristics and beliefs.
5. Experience with continuous quality improvement initiatives.
6. Knowledgeable regarding data collection and interpretation, use of spreadsheets.

Qualifications:

• MSW required
• At least three years of Social Work experience required
• LMSW or LCSW preferred