To provide care coordination and psychosocial services to Patient Aligned Care Team Veterans at the Fort Worth VAMC within the VA North Texas Health Care System. Screening/Assessment/Treatment Planning/Goal Setting The incumbent must use a high level of skill in assessing and treating the complicated psychosocial problems of Veteran?? and their families/significant others. Develops psychosocial treatment plans in coordination with interdisciplinary team members. Social work responsibilities provide crisis management and develops psychosocial and clinical assessment of psychosocial problems that cause distress, often impacting the health condition and creating barriers to care. Administrative Functions a) Is responsible for supporting the mission, policies, and procedures of the Department of Veterans Affairs, the Veterans Health Administration (VHA), the appropriate Veterans Integrated Service Network (VISN), and the facility. b) Is willing to serve on committees, work groups, and task forces at the facility as deemed appropriate by the supervisor and Chief of Social Work Services. Case Management/ Goal Setting/Discharge Planning Provides case management services to Veterans serving as the liaison to other treatment programs. Social workers will engage Veterans and, when appropriate, other members of the Veterans support system, in an ongoing information-gathering and decision-making process to help Veterans identify their goals, strengths and challenges. Resources and Referrals The Social Worker will serve as the subject matter expert on VA and/or community resources. Advocacy The Social Worker will act as an advocate when it serves the best interest of the veteran/family. Crisis Intervention The Social Worker is experienced in making rapid assessments and developing crisis management plans to maintain patient in the home, for admission to acute, short term and/or long-term placements. Patient Education/Whole Health Coaching The Social Worker provide education related to VA and community resources, entitlements, Advance Directives/Living Will and will refer veterans/families to the appropriate interdisciplinary team member for identified health education needs to include Complimentary and Integrative Health Services. Education/Training/Supervision Participates in the orientation of new Social Worker staff and other interdisciplinary team members. Coordination of Non-Institutional and Institutional Services The PACT Social Worker is responsible for the coordination of the referrals of non-institutional services such as but not limited to HBPC, ADHC, home hospice, skilled and non-skilled homecare services, substance abuse or behavioral health programs. Supportive counseling/education The Social Worker will provide Veterans and their caregivers with ongoing supportive counseling and education. Work Schedule: Monday - Friday 8:00am - 4:30pm Telework: Not available Virtual: This is not a virtual position. Position Title/Functional Statement #:Social Worker (PACT)/PD000000 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.