Social Worker
Company: Landmark Health
Location: San Bruno
Posted on: January 12, 2021
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Job Description:
Do you want to make a difference in healthcare?Landmark Health
was created to transform how healthcare is delivered to the most
medically vulnerable members in our community. Our medical group
provides home-based medical care to chronically ill patients, many
of whom are frail, elderly and ill-equipped to navigate our
overwhelming healthcare system.Because many of our patients are
frail and elderly, we deliver care primarily in the comfort of
their home. Our Program is also offered to eligible patients at no
incremental financial cost to them. We are not a fee-for-service
practice; we benefit economically only if we deliver high-quality
patient outcomes and satisfaction. As a result, our clinical teams
can spend quality-time caring for a smaller number of patients,
giving all patients the space, respect, compassion and care they
deserve.Our model is finding success throughout the country; we are
now the nation's largest risk-based, in-home medical group.At
Landmark, our interdisciplinary teams collaboratively manage our
complex patient panels. These teams are led by Physicians, Nurse
Practitioners, and Physician Assistants, with supporting care
provided by RN Nurse Care Managers, Social Workers, Pharmacists,
Behavioral Health and other employed team members.The primary role
of the Social Worker (SW) is to assess the psychosocial needs of
members and provide solution-focused care coordination to address
issues that impede their ability to adhere to their medical care
plan. The SW is an active member of the Interdisciplinary care team
(IDT). Social work services will be provided in home,
telephonically and/ or video.The Social Worker is responsible for:*
Facilitating serious illness / goals of care discussion with the
patient and family* Conducting an assessment of the patient's and
family's strengths and needs; this may be done in the home,
telephonically and or video* Developing collaborative care plan
goals with the patient and family and/ or caregivers and IDT
members* Connecting patient and/ or patient's family/ caregiver to
appropriate community resources and supports* Providing solution
focused case management* Providing brief therapeutic interventions
to patient and family* Utilizing motivational interviewing (MI) and
other psychotherapeutic techniques to elicit behavior change*
Promoting patient and family self-management strategies* Enhancing
connectivity between patients and members of the interdisciplinary
team* Navigating community resources and developing community
partnerships to improve access to care and ease of systems
navigation* Master's Degree (MSW) in Social Work* Meet all state
certification and licensing requirements* Minimum of three (3)
years of social work experience (internship not included)* Minimum
of two (2) years of social work experience in a healthcare setting*
Palliative and/or hospice care experience is preferred* Experience
in delivering home-care or field case management is preferred*
Excellent communication skills and knowledge of accessing community
resources* Possession of a valid state driver's license and access
to an automobileIn order to work with potentially vulnerable
patient populations and to keep employees healthy while caring for
patients, all patient-facing employees of Landmark must provide
evidence of the following required immunizations/vaccinations as a
condition of employment: TB, MMR, Tdap, and Influenza. Declinations
may be accommodated based on your medical history, an allergy or
religious beliefs. Please immediately contact HR if you wish to
apply for an exemption from our vaccination requirements so that we
may determine if you qualify for an accommodation.
Keywords: Landmark Health, San Bruno , Social Worker, Other , San Bruno, California
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