Social Worker; Program Coordinator CCICM

Job Title

Care Coordination and Intensive Case Management Coordinator and Patient Aligned Care Team Clinical Social Worker

75% CCICM Coordinator Duties. 25% PACT Duties

Incumbent serves as the Care Coordination and Intensive Case Management (CC & ICM) Coordinator and Patient Aligned Care Team (PACT) Clinical Social Worker. The incumbent must use a high level of skill in assessing and treating the complicated psychosocial problems of Veterans. 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, their family members, and/or caregivers.

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.

Has primary knowledge of use of medical and mental health diagnoses, disabilities, and treatment procedures. This includes acute, chronic, and traumatic illness, injuries, medical terminology, and common medications and their effects and side effects.

Independently identifies high-risk patients and provides case management services for chronic disease management in collaboration with the multidisciplinary team. Complex cases are staffed regularly with the clinical supervisor. Utilizes the Patient Aligned Care Team (PACT) template assessments to synthesize information into a working document that provides direction in determining the level of care, level of case management and follow up. Differentiates between episodic, supportive, progressive, and intensive case management.

Independently provides crisis intervention services if needed, seeking to address cause, as well as the presenting complaint, coordinates family conferences, and serves as liaison to family members. Formulates a plan with goals, objectives, barriers, and needs based on PACT templates for ongoing follow up and case management.

Independently conducts psychosocial assessments as appropriate for treatment planning. Assessment is to highlight the Veteran's strengths, limitations, internal and external supports, and service needs in order to optimize functional status. Identifies the psychosocial complications that can be caused due to a sudden onset of an acute or chronic illness.

Provides treatment interventions in collaboration with the Veteran and family, interdisciplinary treatment team, and community members. The incumbent possesses knowledge and ability to implement treatment modalities including motivational interviewing (MI) to provide supportive counseling and health coaching to individuals, families, and groups. Incumbent has an understanding of the range of treatment and skills for all adult patients related to illness or chronic medical conditions, psychological needs, and age-associated conditions.

Incumbent possesses the skills to establish therapeutic relationships with Veterans and families, mediate difficulties, and measure outcomes of treatment interventions.

Provides pro-active case management to assist in eliminating barriers to health care interventions based on the level of case management indicated in the initial and follow up assessments. Offers strategies to resolve underlying causal factors and build upon and promote strengths and abilities.

Coordinates community-based services, including information and referral for additional services from other VA programs, other government programs, and community agency programs. Provides education to community care partners regarding general VA benefits and services in the course of care coordination for Veterans. Follows Veteran/Caregiver through continuum of health care.

Has general knowledge of Veterans' benefits and services relating to special programs, service-connected compensation, and non-service-connected pension. Facilitates referrals and applications for benefits based upon Veterans' needs and eligibility.

Provides education to Veterans and families related to VA benefits and services, community resources, entitlements, and completion of Advanced Directives and Living Wills. Refers Veteran and families to the appropriate interdisciplinary team member for…