Social Worker-Home Based Primary Care

Social Worker provides Veterans in the Home-Based Primary Care (HBPC) Program with high quality case management, clinical treatment, advocacy, and coordinate linkage with appropriate VA and community service providers and agencies as needed by the client. Services include psychosocial assessment of Veteran and family needs; individual, group and family counseling; caregiver burden assessments and intervention, and casework services for the purpose of addressing identified needs.

Total Rewards of a Allied Health Professional Screening Assessment: Develop an assessment of the veteran in collaboration with the interdisciplinary treatment team, the veteran, family members, and significant others, whenever possible. Treatment Planning Goal Setting: Responsible for developing the treatment plan and setting achievable goals with the veteran and family in collaboration with the HBPC interdisciplinary treatment team members. Follows policies and procedures developed by Home & Community Based Services (HCBS), HBPC, and the Medical Center that are consistent with patient rights and the maintenance of the patient progress notes, outcomes, discharge, planning, and the patient's treatment plan.

Referral to Service Providers: the Social Worker is a subject matter expert on VA and/or community resource throughout the course of treatment. Social Worker will collaborate with other service providers in reassessing the veteran's needs for non institutional, institutional service programs and entitlements. 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 Development: Responsible for developing a resource file of VA and community social service programs and will refer the veteran to needed services. Advocacy: When appropriate and feasible, social worker will educate and encourage the veteran/family to advocate on their own behalf, thus fostering a sense of independence and empowerment.

Crisis Intervention: Experienced in making rapid assessments and developing crisis management plans to maintain patient in the home, for admission to acute, short-term, and/or long-term placements. Social Worker provides education related to VA and community resources, entitlements, Advanced Directives/Living Wills, Durable Power of Attorney, Physician Orders for Life-Sustaining Treatment, and will refer veterans/families to the appropriate interdisciplinary team member for identified health education needs. Facilitates Complex Care Reviews or Care/Family conference as needed to collaborate and plan for complex needs of veterans with the interdisciplinary team, other professionals and services, and/or family. Responsible for the coordination of referrals of non-institutional services such as Adult Day Health Care (ADHC) or Community ADHC, home hospice, skilled and non-skilled homecare services in collaboration with the interdisciplinary treatment team members.

Provides the veterans and their caregivers with ongoing supportive counseling. May participate as a member of HBPC QA team. May include data collections and analysis, formulating plans to improve systems and re-evaluation of plan success.

Social worker may be requested to conduct Community Nursing Home visits to assess the psychosocial needs of veterans in the community nursing home, and adequacy of care/services provided. Work Schedule: Monday thru Friday 8:00am-4:30pm. Recruitment/Relocation Incentives (Sign-on Bonus): Not Authorized Permanent Change of Station (Relocation Assistance): Not Authorized.

Pay: Competitive salary and regular salary increases. Paid Time Off: 37-50 days of annual paid time offer per year (13-26 days of annual leave, 13 days of sick leave, 11 paid Federal holidays per year) Parental Leave: After 12 months of employment, up to 12 weeks of paid parental leave in connection with the birth, adoption, or foster care placement of a child. Child Care Subsidy: After 60 days of employment, full time employees with a total family income below $144,000 may be eligible for a childcare subsidy up to 25% of total eligible childcare costs for eligible children up to the monthly maximum of $416.66.

Retirement: Traditional federal pension (5 years vesting) and federal 401K with up to 5% in contributions by VA Insurance: Federal health/vision/dental/term life/long-term care (many federal insurance programs can be carried into retirement) Telework: Not Available Virtual: This is not a virtual position. Functional Statement #: 80735-F Permanent Change of Station (PCS): Not Authorized.