Caseworker at risk youth

The Trauma Program Social Work III is an integral member of the multidisciplinary Trauma team and provides comprehensive psychosocial assessment, crisis intervention, patient and family support, resource coordination, behavioral health linkage, longitudinal follow-up, and discharge planning for injured patients across the continuum of care. The Trauma Program Social Worker will follow all trauma patients from admission through discharge, beginning in the Emergency Department and continuing with patients admitted to inpatient units, step-down units, and Intensive Care Units (ICUs). The Social Worker will screen trauma patients from admission, conduct ongoing chart reviews, identify psychosocial and behavioral health needs, coordinate interventions and referrals, and provide continuity of psychosocial care throughout the patient's hospitalization and following discharge. The Social Worker collaborates closely with Trauma Surgery, Emergency Medicine, Nursing, Utilization Management, Rehabilitation, Behavioral Health, Addiction Services and other clinical services to address psychosocial barriers that may affect recovery, safety, adherence, disposition, and reintegration into the community. The position supports trauma-informed, culturally sensitive, patient- and family-centered care and contributes to the Trauma Program's performance improvement, injury prevention, education, community outreach, longitudinal follow-up, and trauma verification-readiness activities. The role is intended to complement, not replace, existing Social Work activities and will provide dedicated trauma-focused psychosocial assessment, intervention, coordination, documentation, and follow-up.

Follow all trauma cases from admission, beginning in the Emergency Department and continuing throughout the patient's hospitalization on inpatient units, step-down units, and Intensive Care Units (ICUs). * Conduct an initial psychosocial screening of trauma patients upon admission and identify patients requiring additional social work intervention based on psychosocial needs, clinical presentation, risk factors, trauma-related criteria, and established Trauma Program protocols. * Support bereavement, grief, end-of-life, and goals-of-care processes in collaboration with the clinical team, Palliative Care, Pastoral Care, and other resources. * Attend daily Trauma Program morning meetings and participate in discussions regarding newly admitted trauma patients, current trauma patients, psychosocial concerns, discharge barriers, behavioral health needs, safety concerns, and follow-up requirements. * Complete timely psychosocial assessments addressing living situation, family/support system, functional status, health literacy, financial and insurance concerns, employment, transportation, caregiving responsibilities, behavioral health needs, substance use, interpersonal safety, and other social determinants that may affect recovery. * Identify barriers to treatment adherence, safe discharge, follow-up care, rehabilitation, and access to medications, equipment, or community services. * Assess patient and family coping, adjustment to injury, and need for additional behavioral health or community support. * Conduct ongoing chart reviews of all trauma patients to identify changes in psychosocial needs, clinical status, discharge barriers, behavioral health concerns, substance-use needs, violence-related concerns, and other factors affecting recovery. * Review relevant documentation from Addiction Counselors/Addiction Services, Behavioral Health, Nursing, Case Management, Rehabilitation, and other clinical disciplines to ensure that identified psychosocial needs are addressed. * Review Addiction Counselor notes and recommendations as part of the trauma patient's ongoing psychosocial assessment and continuity of care. * Conduct ongoing reassessment of trauma patients as clinically indicated and ensure appropriate social work intervention as patient needs change throughout hospitalization. * Use qualified interpreter services when needed and support equitable access to care for patients with limited English proficiency.

Safety, Violence, and High-Risk Needs * Screen and respond to concerns involving interpersonal violence, intimate partner violence, community violence, exploitation, homelessness, and other high-risk social circumstances. * Coordinate mandated reporting when required by law and institutional policy. * Facilitate referrals to appropriate hospital-based and community violence intervention, victim assistance, behavioral health, shelter, legal, and social service resources. * Collaborate with the Trauma Program's injury prevention and outreach activities to identify opportunities for secondary injury prevention and risk reduction. * Address additional needs of vulnerable populations such as the elderly and youth. * Collaborate with Geriatrics and Palliative Care to address goals of care and advance directives. * Collaborate with community violence prevention resources at Lincoln Medical Center, including Lincoln Victim Assistance Program, when appropriate.

Substance Use and Behavioral Health * Work with Addiction Services to identify trauma patients who may benefit from substance-use assessment, brief intervention, treatment referral, or behavioral health evaluation in accordance with institutional protocols. * Coordinate referrals to Addiction Medicine, Behavioral Health, social service agencies, and community treatment resources as appropriate. * Assist with continuity planning for patients with pre-existing psychiatric or substance-use treatment needs. * Identify trauma patients requiring additional behavioral health intervention based on psychosocial assessment, clinical presentation, screening results, and established Trauma Program criteria.

• ITSS Screening, Mental Health Referral, and Trauma-Related Behavioral Health Follow-Up
• Review trauma patients for behavioral health needs utilizing established trauma screening tools and Trauma Program criteria.
• Review ITSS (Injury Trauma Screening Score) results for trauma patients and identify patients who meet established criteria for additional psychosocial or behavioral health follow-up.
• Follow trauma patients who meet established ITSS criteria and ensure that they are appropriately connected with mental health services.
• Coordinate referrals to Behavioral Health, outpatient mental health providers, community mental health agencies, or other appropriate services based on identified needs.
• Track mental health referrals and assist patients in overcoming barriers to establishing or maintaining behavioral health services.
• Communicate identified behavioral health concerns and referral needs to the appropriate members of the interdisciplinary Trauma team.

Develop, maintain, and provide educational materials regarding PTSD and the psychological effects of traumatic injury to trauma patients and families. * Educate patients and families regarding common emotional responses following traumatic injury, coping strategies, warning signs of psychological distress, and when to seek additional mental health support. * Provide trauma-informed education regarding available behavioral health and community resources. * Discharge Planning and Continuity of Care * Coordinate with Case Management, Rehabilitation, Nursing, physicians, therapists, community agencies, and families to support safe and timely disposition. * Collaborate with outpatient nursing services for home assessment and PT in elderly trauma patients. * Assist patients and families with access to community resources, transportation, housing resources, benefits, disability-related resources, victim compensation resources, and other services when applicable. * Support transitions to rehabilitation facilities, skilled nursing facilities, home services, shelters, or other appropriate settings in collaboration with the responsible care-management team. * Promote continuity with trauma clinic, primary care, specialty care, rehabilitation, behavioral health, and community services. * Ensure that psychosocial, behavioral health, substance-use, and safety concerns identified during the hospitalization are communicated to appropriate providers and incorporated into the discharge and follow-up plan.

Conduct structured three-month and six-month follow-up with eligible trauma patients following discharge. * Assess the patient's psychosocial adjustment following traumatic injury, including emotional well-being, PTSD symptoms or concerns, mental health service connection, substance-use treatment needs, social supports, functional adjustment, and community reintegration. * Assess barriers to ongoing recovery, access to services, transportation, housing, employment, benefits, rehabilitation, primary care, behavioral health, and other community resources. * Determine whether patients identified through ITSS screening successfully connected with recommended mental health services. * Document all three-month and six-month follow-up contacts in the electronic medical record in accordance with Trauma Program requirements. * Complete a report on three-month and six-month follow-up activities and findings, including identified psychosocial needs, referrals, behavioral health connections, barriers to care, patient outcomes, and opportunities for program improvement. * Participate in multidisciplinary trauma rounds, case conferences, morning meetings, and other meetings as assigned. * Attend Trauma Program morning meetings on a consistent basis and contribute psychosocial information relevant to patient care and disposition. * Serve as a liaison between the Trauma Program and Social Work/Case Management for complex trauma-related psychosocial issues. * Collaborate with the Trauma Social Work team to ensure continuity of coverage, appropriate handoffs, and comprehensive follow-up of trauma patients. * Collaborate with Injury Prevention, Outreach, Trauma Registry, Nursing, Addiction Services, Behavioral Health, and Trauma Program leadership on initiatives relevant to psychosocial care and community reintegration. * Participate in development and review of trauma-related psychosocial pathways, protocols, educational materials, referral resources, and follow-up processes. * Weekend and Seven-Day Trauma Social Work Coverage * Provide weekend coverage for the Trauma Program to ensure that trauma social work services are available seven days per week. * During weekend coverage, follow trauma patients across the Emergency Department, inpatient units, and ICUs as clinically indicated. * Address urgent psychosocial needs, crisis intervention, family support, safety concerns, discharge planning, behavioral health needs, referrals, and other trauma-related social work needs during weekend coverage. * Conduct appropriate weekend chart reviews and ensure continuity of care between weekday and weekend Trauma Social Work coverage. * Communicate significant psychosocial concerns, interventions, referrals, and outstanding needs to the Trauma Social Work team to support appropriate weekday follow-up. * Collaborate with the Trauma Social Work team to establish an effective seven-day coverage model that minimizes gaps in trauma psychosocial services.

Standardized Trauma Social Work Documentation * Utilize an approved electronic medical record SmartPhrase/SmartText for Trauma Social Work documentation to promote consistent, comprehensive, and standardized documentation. * Use the SmartPhrase to document trauma screening, psychosocial assessment, interventions, referrals, behavioral health needs, ITSS-related follow-up, patient education, safety concerns, discharge planning, and ongoing follow-up. * Participate in periodic review and refinement of the Trauma Social Work SmartPhrase in collaboration with Trauma Program leadership and the Social Work/Case Management team. * Ensure standardized documentation supports Trauma Program performance improvement, data collection, continuity of care, and trauma verification-readiness activities.

Performance Improvement and Patient Safety * Participate in Trauma Performance Improvement and Patient Safety activities when psychosocial factors, discharge barriers, violence, substance use, family communication, behavioral health needs, or social determinants contribute to patient-care issues. * Assist with identification of system opportunities related to psychosocial assessment, referrals, discharge planning, mental health connection, and continuity of care. * Utilize information obtained through trauma chart reviews, ITSS follow-up, three-month and six-month follow-up, and social work interventions to identify trends and opportunities for improvement. * Provide data and qualitative findings regarding trauma psychosocial needs to Trauma Program leadership as requested. * Assist in monitoring compliance with trauma social work screening, intervention, referral, follow-up, and documentation expectations. * Participate in the development and implementation of quality-improvement initiatives addressing psychosocial barriers and behavioral health needs among trauma patients.

A valid Licensed Clinical Social Work (LCSW) license issued by the New York State Education Department and one year of full-time satisfactory post-licensure experience utilizing one or a combination of casework, group work and community organization A valid Licensed Clinical Social Work (LCSW) license issued by the New York State

Provide education to trauma staff, residents, students, and other team members regarding psychosocial aspects of traumatic injury, available resources, trauma-informed care, violence prevention, PTSD, behavioral health, substance-use concerns, and social determinants of health as appropriate. * Develop and provide patient and family educational materials related to PTSD, trauma recovery, coping, behavioral health services, substance-use resources, and community support. * Maintain continuing education and professional credentials required for the applicable Social Work title and scope of practice.

Knowledge of psychosocial issues associated with traumatic injury, PTSD, grief, crisis intervention, behavioral health, substance use, violence, and community reintegration. * Knowledge of community resources, benefits, behavioral health services, substance-use resources, violence-related services, trauma-informed care, and discharge-planning principles. * Ability to communicate effectively with patients, families, clinical teams, community agencies, and multidisciplinary partners in high-acuity and emotionally challenging circumstances. * Ability to work collaboratively within a multidisciplinary Trauma Program and coordinate care across the Emergency Department, inpatient units, ICUs, rehabilitation settings, outpatient services, and community resources. * Ability to provide consistent and standardized electronic medical record documentation, including use of Trauma Social Work SmartPhrase/SmartText documentation. * Ability to attend Trauma Program morning meetings, multidisciplinary rounds, case conferences, performance improvement activities, and other Trauma Program meetings and initiatives as assigned. * Demonstrated interest and commitment to providing trauma-informed, culturally responsive, patient- and family-centered social work services to injured patients and their families.