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Social Worker-Home Based Primary Care
Veterans Health Administration · Posted 5 days ago
About the Role
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.
What You'll Do
- →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.
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 dentification cards that are not REAL ID compliant cannot be utilized as an acceptable form of identification for employment.
- ✓Must pass pre-employment physical examination.
- ✓Must possess a current, valid drivers' license and be cleared to drive and transport veterans.
- ✓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
Job ID: e3ad9e06-b4a4-4555-97c3-f5d702cb5964
Posted via USAJobs