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Ypsilanti Meals on Wheels MSW Social Worker in Ypsilanti, Michigan

Ypsilanti Meals on Wheels (YMOW) is offering a new program called Community Aging-In-Place Advancing Better Living for Elders (CAPABLE) to improve the in-home safety of older adults residing within the service area.uPosition Summary/u:The Clinical Social Worker empowers older adults and medically fragile adults with complex needs to:ulliBuild competencies to claim a leadership role within their healthcare team,/liliAdjust to and prepare for evolving chronic care needs,/liliIdentify resources, and/liliUnderstand changes in their personal health status, prognoses, or treatment plans established by their primary healthcare team/li/ulUsing motivational interviewing skills, the CAPABLE+ Social Worker facilitates discussions about unmet community resource needs related to successful aging-in-place to support the clientrsquo;s ability to develop an appropriate action plan. As a member of the CAPABLE+ interdisciplinary team, the Social Worker provides education and training for clients at risk of maladaptive behaviors, depression, social isolation, falls, potential abuse, and/or has other unmet Social Determinants of Health (SDOH) concerns.In October ndash; December: Ad-hoc short-term project to assist with support to YMOWrsquo;s under 60 medically fragile clients on our waitlist to assist with intake, assessment and Medicaid enrollments for approximately 30-40 local residents of the greater Ypsilanti area. Following this ad-hoc project the social worker will transition to the CAPABLE team.uPrimary Duties and Responsibilities:/uulliSkilled Clinical Social Work service provision for the CAPABLE+ program/li/ululliConduct semi-structured clinical interviews to assess individual psychosocial-emotional healthcare status and unmet needs/li/ululliCompile, record, code client interview and assessment data using specified form(s)/liliCoach clients through a process to identify, prioritize, and problem-solve SDOH barriers/li/ululliEducate, reinforce, and refine client strategy use, coaching the client through effective goal setting that results in informed decision making and behavior change/li/ululliProvide self-management education resources to address gaps in personal competencies plan for future needs/liliDemonstrates the ability to use the various computer programs necessary for tracking client progress outcomes/liliAssist in the planning implementation of CAPABLE+ related quality improvement initiatives/liliParticipate in interdisciplinary CAPABLE+ team meetings/liliMaintain positive, effective communication skills in all interactions/liliAct as a liaison between clinical team, clients, and students/liliAdhere to YMOW organizational policies and procedures including HIPAA standards/liliProvide supplemental Case Management support to the general YMOW clientele as needed/liliMaintain active and current status in profession/liliOther duties as assigned/li/uluJob Demands /uulliManage an active caseload of 20-50 clients per quarter/liliFlexibility in work procedures and schedules/liliAbility to deal with stress in meeting deadlines, writing reports, etc./liliAbi