The Senior Social Worker serves as a core member of the interdisciplinary Home Based Primary Care (HBPC) treatment team which is a specialized program under the administration of Primary Care. Incumbent works autonomously and provides expert level psychosocial interventions and case management services to Veterans with complex medical, social and behavioral conditions in which routine clinic based care is not effective. Senior Social Worker independently provides a comprehensive psychosocial assessment and integrates it into an overall plan of care in collaboration with the interdisciplinary treatment team, the Veteran, family members and significant others, whenever possible. The goal of the assessment is to highlight the veteran's strengths, limitations, and internal/external supports and service needs in order to optimize the Veteran's functional status and safely maintain the veteran in his/her home. The assessment requires a home visit. It is the responsibility of the incumbent, working within the interdisciplinary treatment team, to develop a treatment plan with the Veteran based on this assessment. Incumbent possesses the advanced practice skills to independently make a psychosocial diagnosis and offer psychosocial interventions, and then measures outcomes to interventions. The incumbent participates and can lead weekly interdisciplinary care planning meetings when asked by the HBPC program director. The incumbent is empowered to design systems changes based on observations, data and experience. Ongoing assessments and updating treatment plans are done when necessary or on a quarterly basis given the changing needs as health status changes. The incumbent will address the unique needs of homebound, frail, disabling/chronic and/or dying Veterans. Incumbent is able to coordinate community-based services, including information and referral for additional services from other VA programs, other government programs and community agency programs. Has expert knowledge of Veterans' benefits and services relating to special programs, service connected compensation, and non-service connected pension. Facilitates and prioritizes referrals based upon Veterans needs and eligibility. Incumbent provides 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. Incumbent independently identifies and prioritizes high-risk patients and provides case management services. Incumbent provides crisis intervention services, seeking to address the cause as well as the presenting complaint, coordinates family conferences and serves as liaison to family members. Has working knowledge and experience in use of medical and mental health diagnoses, disabilities and treatment procedures. This includes acute, chronic and traumatic illnesses/injuries, common medications and their effects/side effects, and medical terminology. Incumbent establishes and maintains effective therapeutic relationships with Veterans and their families. Incumbent is able to independently work with patients and families who are experiencing a variety of psychiatric, medical and social problems utilizing individual, group and family counseling and therapy skills. Incumbent must possess advanced knowledge and ability to independently implement treatment modalities, provide counseling or psychotherapy for individuals, families and groups. Incumbent 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. Incumbent utilizes advanced practice skills, professional judgment and expertise regarding the Veteran's self care capability, family support system, and the Veteran's health care needs and possible consequences. In the event of a medical or psychiatric emergency, staff will follow the protocol of the HBPC Program. Incumbent independently provides consultation services to other staff regarding the psychosocial needs of Veterans and the impact of psychosocial problems on health care and adherence to treatment plan. Evaluates own practice through professional peer review, case conferences and other organizational means. Incumbent is able to communicate effectively, both orally and in writing, with people from varied backgrounds. Has working knowledge and skill in the use of word-processing, data management and other computer systems, especially those programs in use by VHA. Driver's License: Unrestricted Required Work Schedule: Monday - Friday; 8:00am to 4:30pm 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.