The 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. Duties to include but not limited to: 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 treatment goals with the Veteran and family in collaboration with the HBPC interdisciplinary treatment team members. The social worker will include psychosocial problems onto the interdisciplinary treatment plan; will attend weekly interdisciplinary care planning meetings. Ongoing assessments and updating treatment plans are done when necessary. Services are via telephone contact and/ or in-person at the homes of Veterans enrolled in HBPC. In home visits will be the primary source of the service interactions. Follow 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: Subject matter expert on VA and/or community resource. 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: Understands the intimidation of bureaucracy and will act as an advocate when It services the best interest of the Veteran/family. 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. Education, Health Promotion and Prevention: Provides education related to VA and community resources, entitlements, Advances 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. Complex Care Review (CCR)/ Care/ Family Conference: Facilitate CCR 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. Relay complex team plans to Veteran act as point of contact when needed. Coordination of non-institutional and institutional services: Responsible for the coordination of the 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. Responsible for the coordination of the referrals of institutional placements in Adult homes, Assisted Living Programs, and Community Nursing Homes. Supportive Counseling: Provide the Veterans and their caregivers with ongoing supportive counseling. The purpose of such counseling is to deal with the psychosocial impact of comping with chronic disabling illness(es), onset of catastrophic illness, and or dying need for non-institutional or institutional services as needed during the course of the Veteran's enrollment in the HBPC program. Administrative Responsibilities: Enter all Veteran/family contacts in the electronic record using appropriate formats and templates. Establish and maintain positive working relationships with employees, volunteers, consumers, and stakeholders within the VA and outside community agencies. Attend all meetings (weekly interdisciplinary treatment team meetings, Social Work staff meetings, quality assurance, etc.) and perform other duties as required by HCBS. Collaborate in the performance improvement process and comply with performance measures as required by the VA. May participate as a member of HBPC QA team. Community Nursing Home (CNH): Conduct CNH visits to assess the psychosocial needs of Veterans in CNH, and adequacy of care/ services provided. Assess the facilities ability to meet Veteran psychosocial needs and make recommendations for compliance with VA standards and policies. Work Schedule: Monday - Friday 0800-1630 Financial Disclosure Report: Not required
Providing Health Care for Veterans: The Veterans Health Administration is America’s largest integrated health care system, providing care at 1,255 health care facilities, including 170 medical centers and 1,074 outpatient sites of care of varying complexity (VHA outpatient clinics), serving 9 million enrolled Veterans each year.