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Legacy Community Health Services: Geriatric Clinic Social Worker

Legacy Community Health Services

This is a Full-time position in Stafford, TX posted August 19, 2021.

Legacy Community Health is a premium, Federally Qualified Health Center (FQHC) that provides comprehensive care to community members regardless of their ability to pay.

Our goal is to treat the entire patient while improving their overall wellness and quality of life, in addition to providing free pregnancy tests, HIV/AIDS screening.

At Legacy, we empower patients to lead better lives by promoting healthy behaviors and offering resources such as literacy classes, family planning services, and nutrition and weight management information.Our roots began in 1981 as the Montrose Clinic, with specialization in HIV education, testing, and treatment.

Since then, the agency has expanded to 10 clinics in Houston, one in Baytown, two in Beaumont, and one in Deer Park with extensive services that include: Adult primary care, HIV/AIDS care, pediatrics, OB/GYN and maternity, dental, vision and behavioral health.

We also service students within KIPP and YES Prep schools.

Legacy is committed to driving healthy change in our communities.Job DescriptionThe Clinic Social Worker I provides a wide range of psychosocial services to patients referred by Legacy providers, including but not limited to: case management, linkages to care, patient advocacy, and psychological and social support.Essential FunctionsWorks within the context of a primary care medical home, applying a team based approach to care while working in partnership with patients/families to promote: timely access to care, understanding of patient care that is culturally sensitive and language appropriate, continuity of care, and the improvement of the whole-person through the teaching of appropriate self-management skills.Identify and screen individuals whom have been referred for social service needs from all Legacy service lines.Assess each patient’s medical and psychosocial history as it pertains to current service needs.Provide information, referrals and assistance with linkage to medical, psychosocial, and basic needs services as needed/requested.Advocate on behalf of patients to decrease service gaps and overcome barriers to services.Educate, support and empower patients to learn and utilize self-management and advocacy skills in order to understand their rights, advocate for their needs, and overcome barriers to services.Monitor the efficacy and quality of services through periodic re-evaluation with peers and supervisor.Adhere to all Clinic Social Work Team guidelines and standards to maintain accurate, timely, and consistent documentation.Participates in Legacy’s Performance Improvement and Quality Assurance Program.Attend training by DSHS/HHSC to become certified under Medicaid’s Case Management for Children and Pregnant Women Program (CPW) and maintain a caseload of CPW patients (licensed staff) (Not the geriatric social worker).o Follow program standards and protocols, including completing Comprehensive Assessments and Service Plans with approved patients.o Maintain paperwork and documentation necessary for program standards.o Stay abreast of all program updates through quarterly webinars and DSHS/HHSC communication regarding program policy updates and changes.Attend one community coalition or community case management meeting monthly.Demonstrate respect and regard for the dignity of all patients, families, visitors and fellow employees to ensure a professional, responsible and courteous environment.Promote effective working relationships and works effectively as part of a team to facilitate the department’s ability to meet its goals and objectives.Attend required training and ongoing education offered by the agency, including, but not limited to: safety trainings and education sessions on Universal Precautions.Must be able to travel between locations as needed.Maintains work area and equipment in condition required by Legacy standards.Performs other duties as assigned.If Clinic Social Worker is seeking Clinical Supervision additional duties will be as follows:o Maintain a direct patient care caseload within the Behavioral Health department, which will include the assessment, diagnosis, and treatment of clients with clinical needs.o Answer and document Risk Assessments.o Meet with LCSW Supervisor on-site for Clinical Supervision sessions as per the Texas State Board of Social Work Examiners requirements.

School-Based Setting:School-based social worker will perform all of the above duties, including CPW, within a school setting for students referred by Legacy providers/staff.Unique Responsibilities:Help strengthen and coordinate Social Services at selected school-based sites across the Houston area.Rotate throughout selected school-based sites to increase accessibility and provider care coordination.Attend scheduled Behavioral Health meetings, District Collaboration Meetings, Community Connection Meetings, and other school meetings as appropriate.Provide educational presentations to Legacy providers and district staff, as needed.Attend school-based provider meetings to engage in problem solving, case discussions, and coordination of care.

Geriatric Clinic Setting:Geriatric social worker will be embedded as an active part of the medical team, located within the medical pods, to promote proactive care coordination, wrap around care, and ease of accessibility for staff and patients.Geriatric social worker will perform all of the above duties, except CPW.Unique Responsibilities:Provide medical case management and care coordination services to elderly and aging patients, and their support systems.Assess psycho-social needs of patients, their support systems, and barriers to care to develop short-term and long-term goals.Develop treatment plans that are designed to improve well-being of patients and their support system.Assist patients in navigating government and community assistance programs (I.E.

completing paperwork, Medicare, Gold Card, SSI/SSDI, etc).Attend collaboration meetings with Legacy medical and behavioral health providers.Collaborate with other Legacy departments in order to enhance and expand Legacy geriatric services.

Education & Training RequirementsCandidates are required to become certified to provide billable services under the DSHS/HHSC Case Management for Children and Pregnant Women (CPW) program and thus must meet all eligibility requirements of the program.All licensed social workers must maintain their professional licenses as defined by the respective Texas licensing/examining boards.Social workers must comply with all applicable recognitions/designations, such as the Independent Practice Recognition as defined by Texas licensing/examining board.Work Experience RequirementsAn LMSW is strongly preferred.

Other candidates that will be considered include: LBSW, and MSW/BSW actively working to obtain licensure.One year or more of medical social work experience preferred.Benefits9 Holiday + 1 Floating HolidayPTO403b Retirement PlanMedical / Vision / Dental (if eligible)

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