Social Worker

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).