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Social Worker-Home Based Primary Care (HBPC)

Veterans Health Administration · Posted 1 days ago

On-siteJackson, MI$70K – $110KApply by Jun 4, 2026Social WorkENFJESFJINFJINFPHealthcare
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About the Role

*Recruitment Incentive Authorized* The Clinical Social Worker provides direct services to adult and geriatric Veterans enrolled in the Home Based Primary Care (HBPC) Program/Specialty PACT 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 collaboration with other members of the HBPC Team or interdisciplinary treatment teams as appropriate.

What You'll Do

  • Duties may 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 support and service needs to optimize the Veteran's functional status and safely maintain the Veteran in his/her home.
  • Within the HBPC Program the assessment will include a home visit.
  • The initial assessment and assessment updates will be completed as specified by the policy for the assigned work area.
  • 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 other HBPC/Specialty PACT 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 other service providers in reassessing the Veteran's needs for non-institutional, institutional services/programs and entitlements.
  • Resource Development - The Social Worker is responsible for developing a resource file of VA and community social service programs and enhancing the content to the benefit of Veterans.
  • 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.
  • Crisis Intervention - The Social Worker is experienced in 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.
  • Education/Health promotion and prevention - The Social Worker provides education related to VA and community resources, entitlements, Advance Directives/Living Will and will refer Veterans and families/significant others to the appropriate interdisciplinary team member for identified health education needs.
  • Coordination of non-institutional and institutional services - The Social Worker is responsible for the coordination of the referrals of non-institutional services such as HBPC, CADHC, home hospice and skilled and non-skilled homecare services in collaboration with the interdisciplinary treatment team members.
  • The Social Worker is also responsible for the coordination of the referrals of institutional placements in Adult Foster Homes, Medical Foster Homes, Assisted Living Programs, CNH, or VA CLC.

Requirements

  • You must be a U.S.
  • Citizen to apply for this job.
  • Selective Service Registration is required for males born after 12/31/1959.
  • Must be proficient in written and spoken English.
  • Subject to background/security investigation.
  • Selected applicants will be required to complete an online onboarding process.
  • Acceptable form(s) of identification will be required to complete pre-employment requirements (https://www.uscis.gov/i-9-central/form-i-9-acceptable-documents).
  • Effective May 7, 2025, driver's licenses or state-issued identification cards that are not REAL ID compliant cannot be utilized as an acceptable form of identification for employment.
  • Must pass pre-employment physical examination.
  • Participation in the seasonal influenza vaccination program is a requirement for all Department of Veterans Affairs Health Care Personnel (HCP).
  • Complete all application requirements detailed in the "Required Documents" section of this announcement.
  • As a condition of employment for accepting this position, you will be required to serve a 1 or 2-year trial period during which we will evaluate your fitness and whether your continued employment advances the public interest.
  • In determining if your employment advances the public interest, we may consider: your performance and conduct; the needs and interests of the agency; whether your continued employment would advance organizational goals of the agency or the Government; and whether your continued employment would advance the efficiency of the Federal service.
  • Upon completion of your trial period, your employment will be terminated unless you receive certification, in writing, that your continued employment advances the public interest.

Personality Fit

This role is commonly a great fit for these MBTI types:

Job ID: a3f9e238-64a0-4cba-a6e5-e476992c0b26

Posted via USAJobs

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