| The Social Work Coordinator of the Transition and Care Management (TCM) Program and the Traumatic Brain Injury (TBI) program oversees all transition activities and the coordination of care and services for Veterans who served in Operation Enduring Freedom (OEF), Operation Iraqi Freedom (OIF), and Operation New Dawn (OND) and are treated at the Charles George VA Medical Center. The Transition and Care Management (TCM) Program and the Traumatic Brain Injury (TBI) Social Worker plans, develops, implements, and evaluates the facility TCM / TBI Program to ensure continual quality improvement and excellence in customer service. Facilitates efficient and appropriate delivery of services across episodes of care within the Medical Center and Community-based Outpatient Clinics (CBOC) The Coordinator practices at an advanced level and has specialized knowledge of practice related to the area of OEF/OIF/OND veterans Plans, develops, implements and oversees all components of facility seamless transition and services provided to OEF/OIF/OND Veterans Develops a system to identify OEF/OIF/OND patients served by the facility and those in the catchment area Responsible for delivering managing and evaluating services to Veterans and their families in the need of acute and chronic management post trauma and rehabilitation services; including case management of complicated TBI OEF/OIF/OND Veterans and active duty veterans Collaborates with other TBI , transition care coordinators within the VA system, the military system, and the community, in order to remain current on information, collective problem solving, and networking opportunities Serves as the facility point of contact for all inquiries regarding seamless transition of OEF/OIF/OND Veterans and as point of contact for OEF/OIF/OND service members and Veterans seeking health care Addresses Congressional inquiries, as well as, VISN and VA Central Office action items as requested Oversees or works closely with facility care management teams to include nurse and social worker case managers, the Visual Impairment Services Team (VIST) Coordinator, the Spinal Cord Injury (SCI) Coordinator and the Women Veterans Program Manager Responsible for ensuring that OEF/OIF/OND Veterans receive comprehensive, as well as, preventive mental and physical health evaluations Promotes and coordinates evaluations for the TCM program for the Medical Center and any outlying CBOCs Prepares program reports for VA Central Office, the VISN Point of Contact (POC), and Medical Center leadership Develops procedures for referrals between the VA Medical Center, Military Treatment Facilities and/or community hospitals that promote appropriate and timely inter-facility transfers Responsible for the management of Military Treatment Facility referrals and the list of combat Veterans located in the facility's catchment area; including entering, editing, compiling, analyzing, and updating of pertinent data Ensures registration of appropriate Veterans for clinical, administrative, and outcome purposes, and manages the training for all staff involved with the registry Responsible for monitoring Veterans Health Administration (VHA) performance monitors and measures related to OIF/OEF/OND to assure they are met or exceeded Establishes performance and outcome standards for the facility TCM/TBI Program that promotes quality and efficiency of services in coordination with the overall goals of the medical center and those of the VISN and VA Central Office Develops policy and procedures to ensure compliance with the Joint Commission, Commission on Accreditation of Rehabilitation Facilities (CARF), and other accrediting bodies and regulatory standards as needed Researches community resources (local, state, and national) that are available to provide continuity of care and to enhance the quality of life of the Veteran, and disseminates information on resources to other TCM Program Managers within the VISN Explores and analyzes community resources including family-friendly delivery systems Identifies unmet needs of the OIF/OEF/OND population and their families and works collaboratively with facility, VISN and VA Central Office staff to develop and implement solutions Ensures that the TCM / TBI Programs are interdisciplinary and fully integrated with the inpatient and outpatient medical programs Coordinates psychosocial evaluation, assessment, and periodic reassessments of OEF/OIF/OND patients served, which provides a comprehensive database to identify psychological, social, and vocational needs and the appropriate treatment and services to be provided Establishes and maintains an ongoing education program for patients, community agencies, students, and staff to facilitate understanding of medical treatment, including clinical practice guidelines, mental health issues, readjustment issues, psychosocial problems, and care giver issues facing the OEF/OIF/OND population Work Schedule: 8:00am - 4:30pm, Monday - Friday Financial Disclosure Report: Not required |
