Social Worker

Job Title

Social Worker

Duties

Duties may include but are not limited to:

• Identifies high-risk patients and provides case management services for chronic disease management in collaboration with the multidisciplinary team. Complex cases are staffed regularly with the clinical social work supervisor. Utilizes the Patient Aligned Care Team (PACT) template assessments to synthesize information into a working document that provides direction in determining the level of care, level of case management and follow up. Differentiates between episodic, supportive, progressive and intensive case management.
• Conducts psychosocial assessments as appropriate for treatment planning. Assessment is to highlight the Veteran's strengths, limitations, internal and external supports, and service needs in order to optimize functional status. Identifies the psychosocial complications that can be caused due to a sudden onset of an acute or chronic illness.
• Provides crisis intervention services if needed, seeking to address cause, as well as the presenting complaint, coordinates family conferences, and serves as liaison to family members. Formulates a plan with goals, objectives, barriers and needs based on PACT templates for ongoing follow up and case management.
• Provides treatment intervention in collaboration with the Veteran and family, interdisciplinary treatment team, and community members. The incumbent possesses knowledge and ability to implement treatment modalities including motivational interviewing (MI) to provide supportive counseling for individuals, families, and groups.
• Provides pro-active case management to assist in eliminating barriers to health care interventions based on the level of case management indicated in the initial and follow-up assessments. Offers strategies to resolve underlying causal factors and build upon and promote strengths and abilities.
• Coordinates community-based services, including information and referral for additional services from other VA programs, other government programs, and community agency programs.
• Provides education to community care partners regarding general VA benefits and services during care coordination for Veterans. Follows Veteran/Caregiver through continuum of health care.
• Facilitates action for community placements through collaboration with Veterans and their families as well as interdisciplinary treatment team members to ensure that appropriate community placements are completed in a timely manner. Community placements can involve but are not limited to referrals to contract nursing homes, Community Living Centers, residential care homes, inpatient and outpatient hospice services.
• Serves as a liaison between Veterans and/or their families and VA and community resources in order to ensure thorough delivery of services.
• Ability to establish and maintain effective therapeutic relationships with Veterans in the Ambulatory Care Clinic and/or their families. The incumbent is able to work with Veterans and their families who are experiencing a wide range of medical, psychiatric, emotional, behavioral, and psychosocial problems.
• The incumbent has primary knowledge of use of medical and mental health diagnoses, disabilities, and treatment procedures. This includes acute, chronic, and traumatic illness, injuries, medical terminology, and common medications and their effects and side effects.