The Senior Social Worker, Home Based Primary Care (HBPC) - Geriatric Extended Care (GEC) provides clinical care and case management to a panel of no more than 100 Veterans enrolled in the Cheyenne VA Healthcare System's GEC spectrum. This includes Veterans with complex and specialized needs, including serious medical, social, and behavioral conditions that require comprehensive, interdisciplinary, primary home care for which routine clinic-based care is not effective or may not be possible. The duties of the Patient Aligned Care Team(PACT) Senior Social Worker HBPC-GEC include but are not limited to: Independently assessing the psychosocial functioning and needs of HBPC-enrolled Veterans and their family members. Identifying Veteran's strengths, stressors, coping skills, and psychosocial acuity. Completing comprehensive initial assessments and follow-up assessments when clinically needed or at least annually. Incorporating complex multiple causation in differential diagnosis and treatment for the geriatric population Utilizes a range of specialized interventions and treatment modalities used in primarily geriatric populations and programs; includes individual, group, and/or family counseling or psychotherapy and advanced level psychosocial and/or case management. Identifying psychosocial issues impacting the patient/caregiver's ability to achieve optimal outcome; implements interventions, including counseling, address psychosocial needs and support patient driven goals of care. Developing a psychosocial plan of care for HBPC enrollees; may include individual/family counseling, long-term and advance care planning, stress management, caregiver respite, psycho-educational programs, and grief and bereavement counseling. Reviewing progress toward goals at regular intervals; quarterly or more frequently when there is a change in the patient's condition. Documenting social work interventions and activities in the Veteran's clinical record according to professional and procedural standards and timelines. Managing consults according to standards and requirements of the facility and regulatory bodies. Assisting with discharge planning for HBPC and GEC patients as indicated; promoting wellness and safety at the highest level of independence. Facilitating access to VA and community resources and services to maximize Veteran SDoH factors; includes services involving housing, in-home assistance and financial support. Keeping the HBPC team informed of available VHA and community resources and benefits for the patient and caregiver. Subject Matter Expert(SME) in matters of health care decision making and decision-making capacity; includes Advance Care Planning, Advanced Directives, Durable Powers of Attorney for Health Care, State Authorized Portable Orders, and Organ Donation. Reviewing existing Advanced Directives with the Veteran and family to ensure accuracy and concurrence with the Veteran's care wishes. Participating in the development and implementation of HBPC and GEC processes for continuous performance improvement. Providing mentorship and supervision to social work students, and/or less experienced social workers. Serving as a role model in the effective operation of an interdisciplinary team. Providing specialized consultation to colleagues and/or students on the psychosocial treatment of geriatric Veterans, as well as role modeling effective social work practice skills. Acting as liaison between VA and community resources, fostering knowledge and collaboration between VA and community partners. Participating in committee assignments as is advantageous to the organization. Work Schedule: Initial work schedule is Monday - Friday from 8:00 AM - 4:30 PM depending on the needs of the HBPC-GEC program, a compressed schedule may be required at a later date. 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.