About this role
SUMMARY: The Master’s Social Worker (MSW) works independently to assess the needs of, coordinate, and deliver social services for participants and families/caregivers. The MSW is a member of the Interdisciplinary Team (IDT) and participates in the assessment, intervention, management, and review of social service needs. The MSW provides care through a variety of modalities, including but not limited to bio-psychosocial assessment, interventions that include cognitive behavioral techniques, psychoeducation, consultation, and care planning/case management.
SPECIFIC DUTIES AND FUNCTIONS:
• The MSW is a member of the IDT and performs a comprehensive bio-psychosocial assessments at the time of enrollment (initial) and 180-day intervals thereafter. Acute assessments are completed on an as-needed basis and aim to answer specific referral questions. Utilizes measurement-based care. • Develops and implements appropriate, individual treatment plans for both participants and caregivers, including but not limited to: • Counseling (utilizing Motivational Interviewing and CBT techniques) • Education • Coordination of services in collaboration with the care team • Risk Assessment/Crisis Intervention
• Directs case management Issues, including but not limited to: • Housing Issues, including identifying least restrictive setting in accordance with participant’s level of income affordability • Financial Issues • Safety Issues including, but not limited to: symptoms of abuse, neglect or exploitation; ability to live independently; decision-making capacity; any other issues warranting involvement of Adult Protective Services (APS) • Psychiatric: changes in mood, behavior, cognition/mental status; suicidal/homicidal ideation; substance use/misuse • Caregiver Burden • Identifies the need to transfer to a higher level of care. • Assists in coordinating discharge planning activities and processes. • Educates and counsels the participant and/or caregiver regarding care needs, options and other related problems. • Advocates to others on behalf of the participant and demonstrates accountability in resolving participant concerns or issues.
• Works collaboratively to develop and communicate initial impressions, plans of care, changes in care, and progress in a timely fashion. • Helps to develop and implement the plan of care with the IDT, participant, and/or caregiver. • Completes timely and accurate documentation in the electronic health record (EHR). • Communicates changes in participants with IDT and family members.
• Evaluates participant outcomes and progress toward achieving the objectives and goals of the care plan and communicates this information among other members of the IDT. • Performs other related duties, as assigned by leader(s).
KNOWLEDGE, SKILLS AND ABILITIES:
• Master’s Social Worker from an accredited school of social work. • Licensed to practice in the State of Michigan. Limited License may be considered depending on experience and number of supervised hours. • One year experience working as a clinical social worker, preferably in the field of geriatrics. • Overall knowledge of case management skills, short term interventions, and principles of human behavior. • Demonstrated knowledge and skill in evaluating, planning, implementing, and monitoring patient-centered approaches to care. • Knowledge of and compliance with applicable local, state, and federal laws and regulations. Cultural competence and an ability to care for a diverse population. • Ability to learn and use electronic health record system. • Proficient in Microsoft Word, Excel, Outlook, PowerPoint. • Positive, flexible, and solution-focused attitude with ability to collaborate effectively in a team setting.