• Support and closely coordinate mental health care with the patient's primary care provider and, when appropriate, other treating mental health providers.
• Screen and assess patients for common mental health and substance abuse disorders.
• Provide patient education about common mental health and substance abuse disorders and available treatment options.
• Monitor patients (in person or by telephone) for changes in clinical symptoms and treatment side effects or complications.
• Support psychotropic medication management prescribed by PCPs, focusing on treatment adherence, side effects and other complications, and effectiveness of treatment.
• Provide brief interventions using evidence-based techniques such as Behavioral Activation, Problem-Solving Treatment, Motivational Interviewing, or other treatments appropriate for primary care settings.
• Provide or facilitate in-clinic or outside referrals to evidence-based psychosocial treatments (e.g., CBT, IPT) as clinically indicated.
• Participate in regularly scheduled (usually weekly) caseload consultation with the psychiatric consultant and communicate resulting treatment recommendations to the patient's PCP.
• Consultations will focus on patients new to treatment or who are not improving as expected.
• Facilitate patient engagement and follow-up in care.
• Track patient follow-up and clinical outcomes using a registry. Document in-person and telephone encounters in the registry and use the system to identify and re-engage patients.
• Document patient progress and treatment recommendations in the registry so they can be easily shared with PCPs, the psychiatric consultant, and other treating providers.
• Facilitate treatment plan changes for patients who are not improving as expected in consultation with the PCP and the psychiatric consultant. These may include changes in medications or psychosocial treatments or appropriate referrals for additional services.
• Facilitate referrals for clinically indicated services outside the primary care clinic (e.g., social services such as housing assistance, vocational rehabilitation, mental health specialty care, substance abuse treatment).
• Complete relapse prevention plan with patients who are in remission.

• Successful completion of an approved Social Work program required.
• Currently a Licensed Clinical Social Worker certification
• Minimum of two years clinical social work experience in community health care environment

Skills/Abilities

• Demonstrated experience developing practice guidelines that are dependent on knowing what the aspects of the situation look and sound like in actual patient situations.
• Demonstrated success in providing clinical care and support within an organization of comparable pace and complexity
• Demonstrated success in managing difficult patient situations, including conflict resolution training
• Significant knowledge of medical practices and procedures within in a primary care environment
• Demonstrated success and familiarity with tools, technology, and systems typically found within most progressive health care environments (i.e. personal computer skills, spreadsheets, word processing, patient records systems, EMR systems, etc.)
• Second language a plus.
• Extensive knowledge of principles, theories, values, and ethics of Behavioral Health treatment practices, including SBIRT, motivational interviewing, and other evidence-based methodologies.
• Must be committed to providing high quality care to underserved and diverse populations.
• Some weekend and evening hours may be required.

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