Senior Social Worker; PACT

Job Title

The Social Worker functions as a Case Manager and Care Coordinator to primary care panels and ensures that health care provided meets the needs defined by the Veterans.

Duties include, but are not limited to:

• Assesses and treats the complicated psychosocial problems of Veterans, families and significant other.
• Reaches out to Veterans with high risk cohort's issues and offers case management in a proactive effort designed to prevent psychosocial crises.
• Provides education and training related to the referral process and services provided. The primary focus is on the acuity level and case management with an understanding for reduction in the acuity level using evidence-based practice that is continuous, accessible and integrated.
• Provides assessment of psychosocial problems that cause distress, can include adjustment to the current medical condition and/or functional status, untreated or under-treated mental health or substance abuse condition, economic instability, legal problems, and inadequate social supports, housing and transportation.
• Assists Veteran and family to understand the contributing factors to their problem(s), will discuss with them the pros and cons of possible short-term and long-term solutions, encouraging them to make positive and lasting changes to reduce stressors
• Makes referrals for assistance to community agencies and will participate in coordinating with VA programs/staff and community agencies to assist in problem solving as needed.
• Engages in case management services with members of the outpatient interdisciplinary team to meet the agreed upon treatment goals.
• Conducts comprehensive assessments of Veterans and develops treatment plans that are sensitive to Veterans' diverse needs and abilities. Independently performs a full range of clinical services including Individual, Group and Family interventions.
• Provides on and off site crisis intervention and outreach (individual sessions, assist and coordinate hospitalizations in conjunction with the physician when required, coordination of treatment with collaterals (family, housing programs, nursing homes, mental health etc.) to maximize the successful stabilization and integration of Veterans in the community both in crisis and non-crisis situations.
• Develops and implements methods for measuring effectiveness of social work practice and services in specialty areas, utilizing outcome evaluations to improve treatment services.

Work Schedule:

Monday - Friday 8:00 a.m.

- 4:30 p.m.

Telework:
Ad hoc telework as determined by agency policy and supervisor discretion

Virtual:
This is not a virtual position.

Relocation/Recruitment

Incentives:

Not Authorized

Permanent Change of Station (PCS):
Not Authorized

Financial Disclosure Report:
Not Authorized