Behavioral Health Specialist, In-Home Care (Mso)

Role Description

The @HOME Behavioral Health Specialist (BHS) is a key resource, contributing a unique and valuable perspective to care teams to support the psychosocial and behavioral needs of patients.  In this role, the Licensed Clinical Social Worker (LCSW) will provide social services and evidence-based short-term psychotherapy to home based patients.  They will assess needs of patients, review goals of care, make referrals to appropriate Behavioral Health resources and specialists, provide short-term counseling and evidence-based treatments as indicated, advocate, assist with advanced care planning/end of life conversations, and coordinate comprehensive care services to our highest-risk patients and their caregivers to help them improve their health status and avoid unnecessary hospitalizations. This is a traveling position that provides in-home primary care to medically complex seniors. 

Program Overview

The House Calls Program (known as @HOME) delivers high-quality primary care to Medicare patients in their home. The @HOME program takes a team-based approach to providing outstanding patient care. Our Care Teams - consisting of a Provider, Medical Assistant/Scribe (CIS/MA), Behavioral Health Specialist (BHS) and Mobile Operations Coordinator (MOC) - build individual relationships across a small panel of patients, seen monthly. The Care Team is responsible for delivering excellent, high-touch primary care, and coordinating the care of patients.

Core Responsibilities

• Support our highest-need patients by providing comprehensive assessments, telephonic check-ins, and in-person visits.

• Collaborate with medical providers to proactively identify and intervene with patients with psychosocial, community resource, and/or Behavioral Health needs 

• Partner with the patient and their support persons (if necessary) to identify goals, increase engagement in their healthcare, address barriers, and drive the execution of their care plan. 

• Maintain extensive knowledge of community resources and make referrals, as appropriate, to help ensure the patient’s healthcare and psychosocial needs are met. 

• Screen and assess patients for common mental health and substance use disorders

• Provide short-term counseling and evidence-based treatments within the Collaborative Care Model

• Provide psychoeducation to patients and families surrounding life stage and disease-specific issues, including dementia, adjustment to illness, aging, caregiver support, etc.

• Provide or facilitate referrals to Oak Street’s psychiatric consultant and/or external resources, as needed

• Facilitate supportive care options (including advance care planning, goals of care and end-of-life care) and provide goals of care counseling, support, guidance and advocacy at all stages of the patient journey.

• Assess patients’ social and behavioral needs and provide community resources and when necessary

• Screen and assess patients for financial assistance and facilitate application for additional resources: LIS assistance for medication, Medicaid, manufacture medical assistance 

• Screen and assess patients for isolation needs and help establish community/connection outside of medical needs

• Recognize mistreatment (abuse / neglect) of patients of all ages, and understand reporting responsibilities of staff who witness abuse / neglect

• Function as the Behavioral Health and community resource expert to care teams and actively participate and present in problem solving present during daily huddles and week interdisciplinary team meetings

• Meet with care teams to collaborate and generate creative solutions to patient issues, and spearhead intervention in situations with complex psychosocial dynamics.

• Accurate and timely documentation of patient encounters and counseling sessions in Oak Street’s electronic medical record

• Other duties, as assigned 

What we’re looking for

• Genuine passion for primary care and reaching vulnerable patients

• Comfort navigating visits in patient homes

• Demonstrated ability to collaborate effectively in a team setting

• Comfort with supporting patients who are facing significant health, psychosocial and/or mental health issues

• Excellent communication, follow-up, teamwork, and problem-solving skills

• Desire to be a part of a fast-paced, innovative, quality-driven organization

Required Qualifications

• Master of Social Work degree required from a school of social work accredited by the Council on Social Work Education (CSWE)

• Clinical Social Worker License (or local equivalent) 

• Experience performing comprehensive biopsychosocial health assessments, mental health and substance abuse disorder assessments

• Experience with assessment and treatment planning for those with common mental health and/or substance use disorders and complex psychosocial needs

• Working knowledge of differential diagnosis and psychosocial treatments of common mental health and/or substance use disorders 

• Proficiency in providing brief, structured intervention techniques (e.g., Motivational Interviewing, Behavioral Activation, Cognitive Behavioral)

• Computer skills:  Ability to quickly navigate and use multiple computer programs to include, but not limited to: Gmail, MS Word or Google Docs, Excel or Google Sheets, etc.

• Someone who embodies being 'Oaky'

• US work authorization

What does being “Oaky” look like?

• Radiating positive energy

• Assuming good intentions

• Creating an unmatched patient experience

• Driving clinical excellence

• Taking ownership and delivering results

• Being relentlessly determined

Why Oak Street Health?

Oak Street Health is on a mission to “Rebuild healthcare as it should be'', providing personalized primary care for older adults on Medicare, with the goal of keeping patients healthy and living life to the fullest. Our innovative care model is centered right in our patient’s communities and focused on the quality of care over volume of services. We’re an organization on the move! With over 150 locations and an ambitious growth trajectory, Oak Street Health is attracting and cultivating team members who embody “Oaky” values and passion for our mission.

Oak Street Health Benefits: 

• Mission-focused career impacting change and measurably improving health outcomes for Medicare patients

• Paid vacation, sick time, and investment/retirement 401K match options

• Health insurance, vision, and dental benefits

Oak Street Health is an equal opportunity employer. We embrace diversity and encourage all interested readers to apply. 

Learn more at www.oakstreethealth.com/diversity-equity-and-inclusion-at-oak-street-health