Employees in this clinical position are responsible for ensuring continuity of services, with a primary responsibility for assuring that the five case management functions are carried out: assessment, planning, linking, monitoring and advocacy. This position functions as an advocate for the participant and a clinical liaison service broker. The employee reports to the Program Director as assigned. This position has no direct supervisory responsibilities. Must strongly believe in recovery and have a commitment to creating and maintaining a culture that expects recovery. The Northern Health Care Management (MI CHOICE Waiver Program) covers 10 counties.
ESSENTIAL POSITION FUNCTIONS (listing Position Specific functions first):
- Ability to work with nursing facility residents, their allies, and facility.
- Inform nursing facility staff of the MI Choice options including residential services option.
- Inform Department of Health and Human Services (DHHS) staff of the MI Choice options including residential services option and work with DHHS to identify Adult Foster Care (AFC) and Homes for the Aged (HFAs) that provide good care.
- Work with DHHS to identify residents who are at high risk of nursing facility admission.
- Conduct research and outreach with AFCs and HFAs to inform them of the requirements and processes for becoming a MI Choice Waiver provider and assess their capacity to meet contract requirements for appropriate care for participants.
- Contact and establish good working relationships with local AFCs and HFAs including identifying those facilities with capacity, specialized services, quality and best practices as possible contract providers.
- Tracking and reporting of information required by MDHHS in a timely fashion.
- Develop and maintain tracking of data on AFC and HFAs for provision of residential services option.
- Coordinate Person-Centered Planning. In doing so, attends to the total spectrum of the individual’s needs, including but not necessarily limited to, housing, family relationship, social activities, education, finance, employment, health, recreation, mobility, protective services and records.
- Initial participant assessments and planning are carried out using a team approach consisting of a RN and a SW as mandated by the MI CHOICE Waiver MDHHS Contract in order to provide a holistic, person-centered perspective. This also provides a foundation for thorough planning of meeting medical needs as well as environmental and psycho-social concerns.
- Collaborate with participants (and staff) assessing their needs, develop treatment goals, objectives, methodologies, timelines, and evaluate progress toward goals.
- Locate, obtain, and coordinate services outside and inside the MI Choice system as indicated by the individual treatment plan.
- Provide supportive services to the participant and his/her family.
- Intervene when necessary to assure implementation of the plan.
- Request, when necessary, review of the individual program plan by the individual’s interdisciplinary team.
- Facilitate interdisciplinary team evaluation and review for assigned participants, as indicated.
- Evaluate, facilitates and monitors services and participants progress in relationship to established goals and objectives and document as appropriate.
- Establish and maintain an effective liaison between the MI Choice Program and outside providers.
- Participate in Quality Assurance case review procedures, including participant satisfaction.
- Monitor treatment plan follow-up, services to participant and over-all conditions. Works with the providers to make necessary improvements. Follow-up problem areas as appropriate.
MINIMUM & EDUCATION & EXPERIENCE:
Bachelor’s Degree in Social Work from an accredited university.
One (1) year of experience in long term care services is preferred.
Experience with skilled nursing facilities and licensed residential homes is preferred.
LICENSING or CERTIFICATIONS:
Must have licensure with the State of Michigan as a Licensed Bachelors Social Worker or Limited Licensed Bachelors Social Worker.
Must maintain licensure.