Social Worker - Patient Aligned Care Team (PACT)

Job Title

The duties include:

- Assist PACT Veterans in navigating care, accessing services, and ensuring follow-up with the PACT team.

- Serve as liaison between VA providers and community agencies.

- Complete psychosocial assessments and coordinate care, linking Veterans and families with needed resources.

- Identify caregiver/family stressors and provide interventions or referrals; determine appropriate case-management level.

- Assess at-risk Veterans in crisis, evaluate needs, and initiate safety plans.

- Build and maintain professional relationships within VA and community partners.

- Provide consultation to staff on Social Work programs.

- Educate Veterans on obtaining a PACT provider and using VA services (VVC, MyHealtheVet, Whole Health, Community Care).

- Conduct assessments via phone, VVC, or in person.

- Provide case management for high-acuity or high-need Veterans (e.g., high CAN scores).

- Protect Veteran privacy and confidentiality per policy.

- Assess and document signs of abuse, neglect, exploitation, or intimate partner violence.

- Participate in facility, VISN, or community committees and work groups.

- Demonstrate knowledge of PACT roles, homelessness factors, discharge planning, and community placement options.

- Facilitate timely community placements with Veterans, families, and interdisciplinary teams.

- Provide consultation to treatment teams on psychosocial factors affecting care and compliance.

- Educate Veterans on VA benefits, services, and community/governmental resources.

- Promote and complete Advance Care Planning and Advance Directives.

- Respond to consults within required timeframes using multiple care modalities.

- Follow suicide-risk procedures including C-SSRS, CSRE, Safety Plans, and SBOR completion.

- Participate in peer review, case conferences, or research to evaluate Social Work practice.

- Support telework, clinic coverage, and care for unassigned Veterans as needed.

- Perform additional duties as assigned.

Work Schedule: Monday - Friday, 7:30 a.m. - 4:00 p.m. or 8:00 a.m. - 4:30 p.m.

Telework: Ad-hoc telework may be available as determined by the agency policy.

Virtual: This is not a virtual position.

Functional Statement #: PD53794-F and PD53793-F

Relocation/Recruitment Incentives: Not Authorized

Permanent Change of Station (PCS): Not Authorized