Social Worker

Job Description

Job Description

Under the leadership of the Social Work Manager, the Masters 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 Participant Care Team (PCT) and the Interdisciplinary Team (IDT) and participates in the assessment, intervention, management, and review of social service needs. The MSW also assists the IDT in determining eligibility and care needs. The MSW provides care through a variety of modalities, including but not limited to, bio-psychosocial assessment, interventions that include individual and group counseling utilizing motivational interviewing, and cognitive behavioral techniques, psychoeducation, consultation, and care planning/case management.
SPECIFIC DUTIES AND FUNCTIONS:
The MSW is a member of the PCT and IDT and performs a comprehensive bio-psychosocial assessments upon enrollment and at 6 and 12 month 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:

Individual and/or group counseling (utilizing Motivational Interviewing and CBT techniques)
Education
Consultation services to the Care Team
Risk Assessment/Crisis Intervention

Directs case management Issues, including but not limited to:

Housing Issues
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 (e.g., Behavioral Health Services).
Assists in coordinating discharge planning activities and processes.o Assists in coordinating 24-hour care as indicated by interdisciplinary team and/or the Care Team.
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 complete 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 or progress toward achieving the objectives and goals of the care plan and communicates this information among other members of the PCT and IDT.
Performs other related duties, as assigned by leader(s).

PACE is a "Best Place to Work" certified company. PACE (Program of All-Inclusive Care for the Elderly) is a unique health plan and care provider, committed to keeping aging adults with challenging healthcare conditions in their homes, by caring for their medical, physical, and social needs. PACE Southeast Michigan provides care and services in the home, the community, and our Day Health Center.

Company Description

PACE is a "Best Place to Work" certified company. PACE (Program of All-Inclusive Care for the Elderly) is a unique health plan and care provider, committed to keeping aging adults with challenging healthcare conditions in their homes, by caring for their medical, physical, and social needs. PACE Southeast Michigan provides care and services in the home, the community, and our Day Health Center.