Social Work
Transform Health MD's Social Work Team provides comprehensive clinical social work services — including assessment, engagement, intervention and evaluation — addressing the overall health of referred patients, but particularly their social and behavioral health needs.
The team can help identify validated screening tools for common behavioral health conditions in primary care. It can also help provide evidence‐based brief interventions telephonically and be a bridge to longer-term and/or specialized behavioral health care via statewide behavioral health resources and a referral database.
Services
- Screening and Assessment – We help providers identify and implement validated screening tools for common behavioral health conditions and social determinants of health. Patients identified and referred to Social Work undergo a comprehensive assessment of their strengths, barriers and readiness for change.
- Patient Engagement – This patient‐centered, collaborative process focuses on identifying, planning and advocating patients as they strive to meet their health goals. Social workers engage in a therapeutic relationship with patients and, when appropriate, family members.
- Care Coordination – The Social Work Team is integrated with the care management team to provide interprofessional care coordination that optimizes patient care. This may include communication with family members, caregiver support and advanced care planning.
- Brief Interventions – This involves use of evidence‐based brief interventions for integrated behavioral health, such as motivational interviewing; screening, brief intervention and referral to treatment (SBIRT); cognitive behavioral therapy; problem-solving therapy; and supportive counseling.
- Education, Information & Referral to Specialized Treatment – As community engagement specialists, we help providers and patients with our deep knowledge of eligibility and application processes for community resources, public health programs and specialized services.
