The Senior Social Worker practices in the Palliative Care Consult Team, and serves a patient population with highly complex health and mental health problems. The Senior Social Worker is assigned to administrative responsibility for clinical program development related to Palliative Care, including coordination of palliative care consults and hospice referrals, and is accountable for clinical program effectiveness and modification of service patterns. The incumbent performs specialized treatment of complex physical and mental illness for patients with diagnoses of cancer or end-of-life diseases. The incumbent serves on multidisciplinary teams working with patients dealing with end-of-life issues, terminal or chronic illness and diagnoses; provides services in an outpatient clinic, inpatient, palliative care unit, inpatient medical/surgical units, and the Transitional Nursing Home Care Unit; provides a consultative service to other areas of the hospital seeking input from palliative care specialists; assesses patient and family needs, and completes biopsychosocial assessments, including multi-axial DSM-5 diagnoses; case manages patients with ongoing needs; provides referrals and coordination of services and resources; counsels patients and families; provides inpatient discharge planning, including placement into skilled nursing facilities or residential care facilities; and provides counseling and assistance with Advanced Directives for Healthcare. The incumbent incorporates complex multiple causation in differential diagnosis and treatment of Veteran patients, including making psychosocial and psychiatric diagnoses within approved clinical privileges or scope of practice. Specific tasks may include: Assessing the patient's understanding of his/her diagnosis and proposed treatments. Helping the Veteran cope with end-of-life or complex chronic illness diagnoses and the many emotions that arise. Education/instruction regarding self-relaxation and other coping strategies. Assessing treatment options when considering work, family and the Veteran's other obligations. Interagency collaboration when the Veteran's care involves multiple entities. Providing education related to the patient's VA, Social Security and disability benefits. Providing referrals and linkage to community agencies with specialized benefits. Counseling individuals, couples and families regarding referrals to specialized mental health providers. Linkage to appropriate support groups and educational programs. Facilitating communication between the treatment team, Veteran and family, including advocacy. Facilitating family discussions regarding illness, healthcare and life changes. Supporting end-of-life planning/care preferences through assistance with Advanced Directives for Healthcare. Discharge planning; inpatient and outpatient placements into residential care facilities, subacute skilled nursing facilities and adult day healthcare programs. Addressing the impact of end-of-life and/or chronic illness on life issues (intimacy, body image, living with chronic illness with the uncertainty of life expectancy, etc.). Providing education or referrals for required transportation to/from palliative and/or, comfort care resources within the VA or in the community. Determining appropriate assistive devices and/or homecare to improve/secure ambulation and continued home safety. Referral to and coordination of hospice care services including facilitation with Non-VA Care Coordination. Advocating for home health or hospice care when requested by the Veteran. Develops and co-facilitates a bereavement support program. Preferred Experience: Hospice/Palliative Care Experience Work Schedule: Monday - Friday (7:30am-4:00pm OR 8:00am - 4:30pm) Virtual: This is not a virtual position. Position Title/Functional Statement #:Senior Social Worker - Palliative Care/PD000000 Permanent Change of Station (PCS): Not Authorized 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.