Geriatric Social Worker: Care Coordination & CBT

**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. #J-18808-Ljbffr Pace