Who We Are & Why We're Different
Our company partners with nephrology practices to implement Value-Based Care (VBC). VBC prioritizes high-touch care coordination for patients with chronic illnesses like chronic kidney disease (CKD). It is an interdisciplinary model where care is developed and perfected with the health of the patient as the primary driver of success. For patients living with CKD, that means slowing the progression of the disease, reducing hospitalizations, and focusing on home dialysis treatment therapies and transplantation if a diagnosis of End Stage Renal Disease occurs.
The Licensed Clinical Social Worker will be at the forefront of this intensive, adaptive, and patient-focused model. We are looking for social work professionals that understand the importance of the "Quadruple Aim", where high-touch interactions between patient and healthcare provider enhance patient experience, improve health outcomes, reduce costs, and improve the work life of the provider.
This Type Of Intensive Service Provision Will Require Social Work Professionals That
As an LCSW you will manage the psychosocial needs of a caseload of patients as they navigate the staged progression of chronic kidney disease (CKD). This will be done by providing disease-specific education in class-based settings, intensive support for complex psychosocial issues and the management of non-medical risk factors as barriers to positive health outcomes. LCSW's will further engage patients considered high risk for advancing CKD progression and unplanned dialysis starts, in one-on-one, in-person home visits, or telehealth encounters, to provide focused education, self-management strategy reinforcement, intensive support, linkage to appropriate resources, and other core social work competencies.
- Can build strong, productive relationships and maintain consistent communication with patients, their families, and providers.
- Manage a caseload of nephrology practice patients and perform monthly clinical needs assessments/complex-case management for high-risk CKD/ESRD patients. The LCSW will focus on addressing psychosocial needs, signs and symptoms of mental health disorders, social determinants of health, and any other risk factors that affect health outcomes. This is done through assessments and care planning during remote engagements and home visits, and the results of validated measurement tools such as:
- The Patient Activation Measure (PAM) for measuring a patient's ability to self-manage their chronic illness.
- The Patient Health Questionnaire (PHQ-9) for identifying signs and symptoms of depression.
- The Accountable Health Communities (AHC) Health-Related Social Needs (HRSN) Screening Tool for measuring patient's community resource needs as they relate to core social determinants of health.
- Educate patients using kidney disease-specific education developed to be culturally appropriate and tailored to a diverse set of learning needs. Topics to include but not limited to the following:
- How the kidneys work.
- The physical symptoms of chronic kidney disease and prevention of uremic complications.
- Co-morbid disease management and the meaning of test results/lab work.
- Impairments in functioning and well-being.
- Different treatment options; including the right to refuse treatment.
- The psychological impact of chronic kidney disease and its impact on family, social life, work, and finances.
- Act as a patient's advocate, liaison, and information resource; escalating all appropriate information to their nephrologist as appropriate. LCSW's will also advocate for VBC by acting as a representative in developing and improving the role in value-based care programs.
- Assess and assist patients for linkage and utilization of appropriate community resources with a focus on complex psychosocial needs in conjunction with other members of the care coordination team.
- Complete timely and accurate documentation per company-documented procedures and relevant professional and regulatory standards
- Perform other duties and responsibilities as required, assigned, or requested.
- Independently clinically diagnosing patients
Education & Experience
Role Incentives & Qualifications
- Master's (Required)
- 1+ years healthcare/medical social work experience
- Nephrology experience preferred
Role Required to Dx
Skills- Technical & Linguistic
- Microsoft Office (required)
- Salesforce, AthenaHealth, other pertinent technology platform
- Languages: English (primary), Spanish (secondary) - preferred not required.
- 60% On location (Patient Home Visits/Nephrology Practice Office)
- 40% Remote
- Health Insurance
- Dental insurance
- Vision insurance
- Life insurance
- Disability insurance
- Paid time off