The incumbent serves as an integral member of the Primary Care Patient Aligned Team (PACT) to outpatient Veterans served by this medical center. Through ongoing therapeutic interventions, the incumbent works with Veterans, spouses, significant others, and adult children in the care planning and treatment process to assist in finding practical solutions to complex problems and life management issues associated with acute and chronic illnesses. FUNCTIONS OF THE POSITION Screening and Assessment The incumbent independently conducts psychosocial assessments, within program prescribed timeframes, to include the Veteran's strengths, limitations, internal/external supports, and service needs in order to optimize the Veteran's functional status and safely maintain the Veteran in their preferred living situation. The incumbent develops and implements realistic and achievable psychosocial treatment plans and goals as part of the PACT treatment plans reflecting effective utilization of a broad range of treatment modalities and interventions. He/She further possesses the skills to measure outcomes of provided psychosocial interventions. The incumbent applies a working knowledge and experience in use of medical and mental health diagnoses, disabilities and treatment procedures for acute, chronic, and traumatic illness/injuries, common medications including their effects and side effects, non-pharmacological pain interventions, stress management, and, medical terminology. He/She applies knowledge of social determinants of health to the assessment of need and risk. The incumbent evaluates the acuteness of need for psychosocial intervention and case management services based on high risk factors such as suicide, intimate partner violence, adult abuse/neglect, food insecurity, homelessness, terminal illness, competency/guardianship, and other acute psychosocial stressors. He/She identifies the need for adaptive equipment and works with the interdisciplinary team to coordinate. The incumbent assesses for home health and non-institutional care needs. Assessments identify psychosocial issues impacting the patient/caregiver's ability to achieve optimal outcomes and implementing interventions. Based upon the assessment, social work case management addresses psychosocial needs and supports patient driven goals of care. Treatment Planning The incumbent develops achievable Veteran centric care/treatment plans and discharge plans (when indicated) in collaboration with the interdisciplinary treatment team, the Veteran, and family members/significant others. He/She addresses the unique needs of the Veteran including, homebound, frail, disabling/chronic conditions, end of life needs, and food insecurity. The incumbent is responsible for educating the Veteran and/or caregiver of the availability of services and assist them in accessing appropriate/preferred resources. Ongoing assessments and updating of treatment plans will occur at prescribed intervals or as clinically indicated. He/She participates in the development of the individual plan of care at interdisciplinary care meetings for assigned panel of patients. Resource Referral/ Development The incumbent serves as the subject matter expert on VA and community resources, collaborating with other services providers. He/She applies their general knowledge of Veterans' benefits and services related to special programs, service connection compensation, and non-service connected pension to assist with application processes and referrals. The incumbent develops a resource file of VA and community resources and collaborates with other VA social workers to keep the file comprehensive and current. He/She coordinates community based services, including information and referral for services from other VA programs, other government programs, and community agency programs. The incumbent facilitates referrals based upon Veteran need and eligibility. The incumbent refers eligible Veterans for non-institutional care. Crisis Intervention The incumbent provides crisis intervention services, seeking to address causation as well as presenting complaints. He/She makes rapid assessments and develop crisis management plans to return Veterans to a state of homeostasis including maintaining Veteran in the home, admission to acute, psychiatric, or short term/long term placements. The incumbent establishes and maintains effective therapeutic relationships with Veterans and their families. Advocacy The incumbent delivers service from a Veteran-centric perspective. He/She acts as an advocate on behalf of the Veteran when it serves the best interest of the Veteran/family. When appropriate and feasible, the incumbent educates and encourages the Veteran/family to advocate on their own behalf in order to promote a sense of independence and empowerment. Work Schedule: Monday - Friday 8:00 AM - 4:30 PM Compressed/Flexible: Yes Telework: Yes Virtual: This is not a virtual position. Position Title/Functional Statement #:Social Worker (PACT)/PD000000 Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized Financial Disclosure Report: Not required
Providing Health Care for Veterans: The Veterans Health Administration is America’s largest integrated health care system, providing care at 1,255 health care facilities, including 170 medical centers and 1,074 outpatient sites of care of varying complexity (VHA outpatient clinics), serving 9 million enrolled Veterans each year.