Social Worker - Patient Aligned Care Team - PACT

Job Title

VA Careers
- Licensed Clinical Social Worker

The Social Work function is to be responsible for the implementation of Primary Care Clinic Social Work services to the veteran population enrolled at the Harry S Truman Veterans Memorial Hospital including Community Base Outpatient Clinics (CBOC). There may be assignments in-patient or other specialty programs. Services include a high level of skill in assessing and treating the complicated psychosocial problems of veterans and/or their family members/significant others.

Referrals typically originate from members of the interdisciplinary team, from veterans and/or their family members/significant others coming as walk-ins to seek assistance, and from community professionals. Working with various patient populations include, but are not limited to, homeless veterans, Hospice Services, Community Living Center, Home Health services, financial resources, contract nursing home, VA benefits, and transportation services. This is accomplished in collaboration with other members of the interdisciplinary team.

Duties include but are not limited to the following:

• Screening/Assessment
  - Social Worker maintains responsibility for psychosocial assessment, case management, and other collaboration with the interdisciplinary treatment team (s), the veteran, family members or significant others. Progress notes are reviewed from other interdisciplinary team providers to accurately determine the strengths and limitations of each veteran. The assessment highlights the veteran's strengths, limitations, and internal/external supports and service needs in order to optimize the veteran's functional status.
• Incumbent assesses at-risk factors and develops a preliminary disposition plan involving veteran, family members or significant others.
• Treatment Planning/Goal Setting
  - The Social worker is responsible for developing the treatment plan with the assigned team and setting achievable treatment goals with the veteran, family or significant other.
• Incumbent provides independent consultation and makes recommendations to the interdisciplinary team on course of treatment.
• Referral to service providers
  - Social Worker is the subject matter expert on VA and/or community resources.
• Incumbent is responsible for educating the veteran and/or caregiver of the available services and assisting them in establishing the appropriate referrals based on the veteran's preference or that of his surrogate decision-maker.
• Resource Usage/Development
  - Social Worker maintains responsibility for using the current Social Work resource file of VA and community social service programs to educate and implement benefits for the veteran. Incumbent refers the veteran to needed services.
• Advocacy
  - Social Worker understands the bureaucracy and will act as an advocate when it serves the best interest of the veteran, family or significant other.
• Incumbent will educate and encourage the veteran, family or significant other to advocate on their own behalf, thus fostering a sense of independence and empowerment.
• Crisis Intervention
  - Social Worker uses advance practice skills in making rapid assessments and developing crisis management plans.
• Incumbent has access to multiple resource directories in addition to previously developed resources to meet the demands of a crisis.
• Education/Health promotion and prevention
  - Social Worker provides education related to VA and community resources, entitlements, Advance Directives/Living Will and refers veterans, families or significant others to the appropriate interdisciplinary team member for identified health education needs.
• Coordination of non-institutional and institutional services
  - Social worker will review the progress notes from other providers to accurately determine the strengths and limitations of each veteran.
• Supportive counseling
  - Social worker provides the veterans and their caregivers with ongoing supportive counseling or short-term solution focused counseling.
• Administrative responsibilities
  - Social Worker enters clinically significant information from veteran, family or significant other contacts in the electronic record using appropriate formats and templates. This information will be entered in a complete, confidential, and professional manner to insure information on the veteran is shared with other VA staff.

Work Schedule:

Monday
- Friday, 8:00am
-4:30pm

Telework:
Not Available

Functional Statement #:
Social Worker FS/000000

EDRP Authorized:
Former EDRP participants…