The LMSW Care Coordinator works within the context of a primary care medical home, from a team approach, and in continuous partnership with families and physicians to promote: timely access to needed care, comprehension and continuity of care, and the enhancement of child and family well-being. Provides care and treatment where applicable 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 in order to promote health and well-being. Provides Care Coordination in the Primary Care setting by utilizing critical thinking skills and social worker expertise in order to optimize patient outcomes amongst designated populations within the practice. 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.

Essential Functions

Assist with or promote the identification of patients in the practice with special health care, Behavioral Health, and chronic illness needs. Will act as a liaison within the primary care practice team. Monitors and utilizes registries to plan and monitor care including but not limited to chronic/preventative patient registries/lists.

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.

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.

Build care relationships among family and team; support the primary care-giving role of the family.

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.

Case management coordination of services such as, transportation, referrals, post-hospitalization discharge; 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.

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. Make referrals to Nemours Financial Assistance Department and support procurement of patient health insurance, as needed

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.

Collaborates with the practice on the NCQA process at the office working in close collaboration with the Medical Home liaison. Promotes/documents Quality Improvement Cycles.

Facilitate referral to behavioral health visits as needed.

LMSW or LCSW Required