Lahey Health Social Worker Medicare ACO Population in Beverly, Massachusetts


Position Summary:

The Social Worker, Medicare ACO Population, addresses both the individual?s psychosocial status, as well as the state of the individual?s healthcare support system, therefore, interventions occur at the patient and family, as well as the system level. It requires the Social Worker to develop and maintain 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. Services provided under the rubric of Social Work Case Management practice may be located in a single hospital / agency / system or may be spread across numerous different organizations.

Utilizing medical management techniques the Social Worker will achieve avoidance of hospitalization when possible and to shorten unavoidable hospital stays and reduce costs by discouraging the unnecessary use of medical services. Thus insuring that the patient obtains the best and most appropriate treatment by encouraging the most effective cost efficient use of health care and / or social services.

Provides care coordination for a patient's care through the care continuum including hospital stay, post-acute care and chronic care community services. Consistent with the Triple Aim, The Social Worker seeks to enhance quality and patient experience of care while eliminating unnecessary costs for patients by ensuring a highly favorable patient experience of care with respect to care transitions between levels of care both within and beyond Lahey Health.

Working with the healthcare team, the Social Worker monitors appropriate utilization of healthcare resources, 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 physical and psychosocial functioning with attention to the social and emotional impact of illness and disability.

The Social Worker for the Medicare ACO Population upholds the current standards of social work case management practice, and reports to the Director, Ambulatory Care Management, LCPN.

Essential Duties & Responsibilities (including but not limited to):

  • The Social Worker is expected to and is 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.

  • Delivers care that is specific to the age/ability of the patient.

  • Evaluates effectiveness of care and adapts plan based on patient/caregiver response.

  • Establishes professional relationship with nurses, physicians, pharmacists, and other health team members.

  • Supports Lahey Health?s commitment to community based resources both within the Lahey community and beyond.

  • Participates in development of a high performing Accountable Care Organization (ACO) with a Patient Centered Medical Home (PCMH) emphasis collaborating with all disciplines with a specific focus on tangible outcomes related to improved quality, patient / provider satisfaction, and decreased costs.

  • Aims to improve the individual'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 care and connect to social and community services.

  • Advocates for patient and families, responds to and facilitates resolution of patient questions and concerns.

  • Provides care coordination for individuals with multiple social stressors and 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.

  • Provides outreach and support to individuals with a history of high utilization of healthcare services including but not limited to emergency department, behavioral health services and/or substance abuse.

  • Assists in obtaining advanced directives, health, social and community services, including but not limited to arranging transportation to medical appointments.

  • The Social Worker works independently providing case management services based on a comprehensive psychosocial assessment that includes addressing advanced directives, 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.

  • Reassessment is an ongoing process, with a formal reassessment conducted at prescribed intervals and whenever there is a significant change in the patient?s health, abilities, living situation, and family involvement.

  • The Social Worker works collaboratively with other professionals to maintain a team-oriented approach to case management and incorporates shared decision making in all patient interactions.

  • Together, the Social Worker, patient/caregiver and healthcare provider formulate an individualized effective case management plan of care and implementation strategies. The plan will identify the patient?s strengths and support systems and utilize them in implementation strategies.

  • Participates in quality improvement activities aimed to improve patient-population outcomes and associated processes.

  • The Social Worker 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.

  • The Social Worker interacts with nurse case managers, pharmacists, providers 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.

Leadership Competencies

  • Demonstrates professional behavior by adhering to unit policies and procedures, practice guidelines specific to the setting and the National Association of Social Workers Code of Ethics.

  • Demonstrates skills as a responsive team member.

  • Demonstrates clinical leadership as evidenced by supporting research and development of care pathways.

  • Demonstrates role of social worker as teacher and coach.

  • Demonstrate ability to fulfill role in regulatory compliance and readiness.

  • Practice in accordance with applicable state and federal regulations, statutes, and laws.

Organizational Requirements:

Maintains strict adherence to the Lahey Health Confidentiality policy.

Incorporates Lahey Health Standards of Behavior and Guiding Principles into daily activities.

Complies with all Lahey Health Policies.

Complies with behavioral expectations of the department and Lahey Health.

Maintains courteous and effective interactions with colleagues and patients.

Demonstrates an understanding of the job description, performance expectations, & competency assessment.

Demonstrates a commitment toward meeting and exceeding the needs of our customers and consistently adheres to Customer Service standards.

Participates in departmental and/or interdepartmental quality improvement activities.

Participates in and successfully completes Mandatory Education.

Performs all other duties as needed or directed to meet the needs of the department.


Minimum Qualifications:

Education: LICSW, Masters in Social Work

Licensure, Certification & Registration: Current Active, unrestricted Massachusetts Social Work License required.

Experience: A minimum of 5 years? medical or community based social work experience.

  1. Excellent clinical, interpersonal and communication skills. Must be able to work collaboratively with other healthcare professionals as well as independently. Experience working with the chronic, complex population in a physician management service organization is desirable.

  2. Must be proactive, assertive, and possess creative problem solving skills.

  3. Experience with Medicare population, managed care, ACO, medical home or integrated case management environment highly desirable.

  4. Must be proficient in computer skills, internet, information technology and electronic medical record use. Epic experience highly desirable.

Skills, Knowledge & Abilities:

  1. Demonstrates expert practice skills that include flexibility, priority setting, problem-solving, conflict resolution, negotiating and networking skills, decision making, work delegation and organization, and verbal / written communication skills.

  2. Demonstrates effective teaching techniques applying adult learning principles.

  3. Demonstrates ability to coordinate appropriate educational materials for patients and their support systems.

  4. Demonstrates sound knowledge bases and actions in the decision making process for designated patient populations.

  5. Excellent interpersonal and organizational skills.

  6. Knowledge base of psychosocial care, case management, social work, community resources and related regulations.

  7. Ability to manage and provide leadership to an interdisciplinary group.



About Lahey Health

The Lahey Model of Care - right care, right time, right place - is exactly what patients, providers and payers need and deserve. Identifying and delivering on this convergence of interests has positioned Lahey Health for further growth. Our model ensures care is highly coordinated and locally delivered, with lower costs and exceptional quality.

Lahey Health is a robust, regional system including a teaching hospital, community hospitals, primary care providers, specialists, behavioral and home health services, skilled nursing and rehabilitation facilities, and senior care resources throughout northeastern Massachusetts and southern New Hampshire. The system has a global presence with programs in Canada, Jordan and Bermuda.

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Lahey Health

Mental Health, Other, Social Work

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