To connect providers and patients to comprehensive clinical social work services, including assessment, engagement, intervention and evaluation addressing the social and behavioral health needs of referred patients, especially as they relate to the overall health of the individual patient. To assist with screening for common behavioral health conditions in primary care, as well as provide evidence-based brief interventions, telephonic behavioral health consultation, and a statewide behavioral health resource and referral database.


  • Screening and Assessment – Assist providers in identifying and implementing validated screening tools for common behavioral health conditions and social determinants of health. Patients identified and referred to Social Work receive a comprehensive assessment including patient strengths, barriers and readiness for change
  • Patient Engagement – Social Workers engage in a therapeutic relationship with patients and when appropriate, family members. This patient-centered and collaborative process is focused on identifying, planning, advocating and supporting patients in meeting health goals
  • Care Coordination – The Social Work Team is integrated with the Care Management Team to provide inter-professional care coordination that optimizes patient care. This may also include communication with family members, providing caregiver support and advanced care planning
  • Brief Interventions – Use of evidence-based, brief interventions for integrated behavioral health, such as Motivational Interviewing, SBIRT: Screening, Brief Intervention, and Referral to Treatment, Cognitive Behavioral Therapy, Problem- Solving Therapy, and supportive counseling
  • Education, Information & Referral to Specialized Treatment – Social Work also assists providers and patients as a community engagement specialist, with deep knowledge of eligibility and application processes for community resources, public health programs and specialized services
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