The Patient Aligned Care Team is a comprehensive team which delivers primary care to Veteran patients in a longitudinal rather than episodic fashion and which has as its focus: prevention; health promotion, coordination and chronic disease management. The social worker in this Veteran-Centric approach often functions as a care coordinator with a panel of Veterans to ensure that health care meets the needs, as defined by the Veteran. Duties include, but are not limited to: Complete thorough assessments to determine the underlying causes of the presenting problem(s), the interpersonal and environmental factors impacting the problem, and its affect on the patient's ability and desire to comply with the treatment recommendations by the multidisciplinary team. Help the patient and family to understand the contributing factors to the problem(s), will discuss with them the pros and cons of possible short-term and long-term solutions, encouraging them to make positive and lasting changes to reduce stressors. Coordinate with VA staff and community agencies to assist in problem solving as needed. Able to independently work with Veterans and their families who are experiencing a wide range of complicated medical, psychiatric, emotional, behavioral, financial, legal and psychosocial problems. Independently complete thorough psychosocial assessments to determine the psychosocial functioning and needs of Veterans and/or their families. Serve as a liaison between Veterans and/or their families and VA and community resources in order to ensure thorough delivery of services. Responsible for supporting the mission, policies, and procedures of the Department of Veterans Affairs, the Veterans Health Administration (VHA), the appropriate Veterans Integrated Service Network (VISN), and the facility. Serve on committees, work groups, and task forces at the facility as deemed appropriate by the supervisor and Chief of Social Work Services. Provide assistance with the orientation and learning of less experienced social workers and, if interested, to serve as a field instructor for graduate level social work students. Demonstrate knowledge and skill in the use of software applications for drafting documents and data management as well as other computer systems in use by the VHA. Other duties as assigned. Work Schedule: Monday - Friday, 8:00am - 4:30pm 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.