Social Worker - (Home Based Primary Care

Social Worker (Home Based Primary Care)

The Clinical Social Worker in this position provides direct services to adult and geriatric veterans enrolled in the Home Based Primary Care (HBPC) Program with high quality case management, clinical treatment, advocacy, and to coordinate linkage with appropriate VA and community service providers/agencies as needed by the client. This is accomplished in the collaboration with other members of the HBPC Team.

This position is responsible for assessment, planning, and provision of case management services in the HBPC Program. The Clinical Social Worker coordinates a variety of activities including outreach, interdisciplinary activities, psychosocial assessments, treatment planning, consultation/education to Medical Center staff and Community Based Service Providers, the collection and maintenance of statistical data, program planning evaluation and modification, and supervision of students as assigned.

Duties include but are not limited to:

• Screening/Assessment:
  The Social Worker will develop an assessment of the Veteran in collaboration with the interdisciplinary treatment team, the Veteran, and family members/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.
• 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, family members/significant others and the other HBPC clinical staff.
• 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 the other service providers in reassessing the Veteran's needs for non-institutional, institutional service/programs and entitlements. The Social Worker is responsible for educating the Veteran and families/significant others 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 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 the 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/significant others. 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.
• Crisis Intervention:
  The Social Worker is experienced in the making rapid assessments and developing crisis management plans. The Social Worker has access to multiple resource directories in addition to previously developed resources to meet the demands of a crisis. In the event of a medical or psychiatric emergency, the Social Worker will follow the protocol of HBPC Program and White River Junction VA Medical Center.
• Performs additional duties as assigned.