Social Worker; Clinical

Social Worker (Medical, Licensed, Clinical, Licensed Clinical, Home Health, Hospice)

Clinical Social Worker, Schofield Barracks, Honolulu HI.

About the Position: This position is located at the Soldier Centered Medical Home inside the Desmond T Doss Health Clinic located on Schofield Barracks, Hawaii.

This is a Direct Hire Solicitation

Tripler Army Medical Center serves as the premier Health Readiness Platform in the Pacific by providing high quality, safe, patient centered healthcare, sustaining and building medical capacity and capability, and ensuring a medically ready force in order to optimize the health, readiness, and resiliency of America's Fighting Forces and all we are honored to serve.

Department of Rehabilitation Services Mission:
Provide patient-focused collaborative care grounded in quality, safety, wellness, population health and innovation to enable readiness and conserve the fighting strength for all.

The Vision of the Department of Rehabilitation Services is to provide world-class, interdisciplinary rehabilitative services, comprehensive pain management, and electro-diagnostic services to enhance military readiness and maximal return of function to our nation’s Service members, beneficiaries, and retirees.

Functions as a full-time integrated team member in the primary care clinic using the Primary Care Behavioral Health (PCBH) model of service delivery. Screens and assesses patients, and performs PCBH model appropriate biopsychosocial evaluations using expert knowledge of general and specific concepts, principles, procedures, and practices relating to clinical, clinical health, and primary care psychology. Provides targeted assessment and evaluation of functional status focused in the context of the presenting problem.

Conducts brief assessments and formulates evidence-based interventions appropriate to a primary care setting for a wide range of behavioral health conditions, chronic medical conditions, and health behaviors affecting medical conditions. Provides evaluation, intervention and relapse prevention services in appointments lasting no more than 30 minutes for initial and follow-up visits. Uses a stepped-care approach to maximize delivery of care within the PCMH.

Triage and refers patients to Specialty Behavioral Health Care when services required exceed the BHC scope of practice. Assists with implementation and monitoring of treatment plans with Primary Care Managers (PCMs) and other primary care team members. Use objective and measurable outcomes to evaluate treatment effectiveness and make adjustments if appropriate for increased adherence and efficacy. Provide high level expertise in human behavior as a primary care team member to develop and support specific clinical pathways or best practice programs for targeted patient groups (e.g., patients with acute stress symptoms, chronic medical conditions, insomnia).

Provides concise documentation of care and recommendations in patient’s medical record beginning in the appointment and completed in no more than 72 hours after the patient is seen.

Provides timely and succinct feedback to PCMs regarding consultation findings and recommendations as directed by the current DHA PCBH Administrative Instruction and DHA Procedures Manual. Determines if patient is appropriate to receive PCBH model services in the primary care setting. Provides ongoing consultation services for a subset of patients who would benefit from periodic, regular behavioral health monitoring and intervention for sustaining improvement and preventing relapse (i.e., continuity consultation).

Participates in all PCMH activities to include huddles, provider meetings, peer review, and trainings. Actively works with PCMH team to identify patients who are appropriate for BHC services and facilitates processes to increase same-day “warm handoff” of patients from PCMs to BHC. Works to increase overall penetration into the enrolled clinic population by targeting common conditions with behavioral components that are amenable to BHC intervention.

Per…