The incumbent serves as an integral member of the Primary Care Patient Aligned Team (PACT) to outpatient Veterans served by the James E. Van Zandt VAMC. Through ongoing therapeutic interventions, the incumbent works with Veterans, spouses, significant others, and adult children in the care planning and treatment process to assist in finding practical solutions to complex problems and life management issues associated with acute and chronic illnesses. PACT Social Worker actively advocates on behalf of the Veteran to ensure services and benefits are obtained. This is accomplished in collaboration with other members of the PACT Team, other interdisciplinary staff, Veterans/caregivers, and community stakeholders. The incumbent is responsible for contributing to the adherence of PACT program standards and policies in an effective and efficient manner. Functions of the position including but not limited to the following: Conduct triage and psychosocial assessments to determine needs of the Veterans and family members. Active participant in the treatment planning process of assigned cases with other disciplines. Participate in discharge planning with other disciplines and will be responsible for ensuring that discharge plans are executed in a manner that is timely and appropriate. Provide consultation/education to Veterans and families on community resources, advance directives Act as a consultant to other team/staff members. Demonstrate and educate Veterans, caregivers and interdisciplinary treatment team members on the impacts of Social Determinants of Health. Act as a liaison between VA and community resources, to include marketing and public relation duties as needed. Provide case management to Veterans and families, as needed, throughout the continuum of care. Address Advance Directives and Organ Donation through the completion of appropriate assessments and supportive services. Provide wellness/prevention education and facilitate patient/family support groups. Supervise the practice of social work students, or a less experienced social worker. Coordinate treatment and communicate with the care lines to facilitate continuity of care. Participate in committee assignments, and meetings. Assist patients, caregivers with coping and dealing with the loss and grief experiences in disability, terminal illness, and death. Provide individual, group, and family counseling. Document social work interventions and activities in patient's clinical record utilizing CPRS and ensure appropriate hand off when transferring of patient care. Participate in a rotation of on-call social workers, including modification of tour of duty to accommodate patient care needs on weekends and holidays as deemed necessary. performs other related duties as assigned. Work Schedule: Monday -Friday; 8:00am to 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.