Social Worker - Patient Aligned Care Team

Social Work Responsibilities

Social work responsibilities include the assessment of psychosocial problems, often at a time when the veteran is experiencing crisis and include the provision of short-term, solution-focused counseling with 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. The incumbent must complete thorough assessments to determine the presenting problem to determine in-home factors impacting the problem and to determine obstacles to treatment and/or follow through with recommended treatments.

Consultation with members of an outpatient interdisciplinary team is provided in order to coordinate a collaborative effort to meet the agreed upon goals for the veteran's treatment needs and include liaison with community professionals regarding needed services for veterans and/or their families. Working with various patient populations include, but are not limited to, homeless veterans, Hospice Services, Community Living Center, Home Health services, financial resources, VA benefits, and transportation services.

Major Duties and Responsibilities

• Screening/Assessment
  - The social worker will complete an assessment of the veteran in collaboration with the interdisciplinary treatment team, the veteran, family members and significant others. The goal of the assessment is to identify needs and formulate a plan to meet those needs. The incumbent demonstrates an understanding of the range of treatment and skills needed for all adult patients including geriatric patients related to their physical limitations, psychological needs and age associated illnesses and conditions
• Treatment Planning/Goal Setting
  - The Social Worker is responsible for contributing to the development of the treatment plan and setting achievable treatment goals with the veteran and family members/caregiver
• Referral to service providers
  - Throughout the course of treatment, the Social Worker is the subject matter expert on VA and/or community resources. The Social Worker will collaborate with other service providers in reassessing the veteran's needs. The Social Worker is responsible for educating the veteran and family members/caregivers 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
  - The Social Worker is responsible for using the current Social Work resource file of VA and community social service programs and enhancing the content to the benefit of veterans. The Social Worker will refer the veteran to needed services
• Advocacy
  - The Social Worker understands the intimidation of bureaucracy and will act as an advocate when it serves the best interest of the veteran and family members/caregiver. When appropriate and feasible, the Social Worker will educate and encourage the veteran to advocate on his/her own behalf, thus fostering a sense of independence and empowerment.
• Other Duties As Assigned