Social Worker-Patient Aligned Care Team

Job Title

PACT Model Social Worker

Duties

The PACT model delivers primary care to Veteran patients in a comprehensive, longitudinal manner, rather than episodic care, with a focus on prevention, health promotion, coordination, and chronic disease management. In this Veteran-centric approach, the PACT social worker often serves as a care coordinator, managing a panel of Veterans to ensure that their health care needs, as defined by the Veteran, are effectively met.

Clinical Functions:

• Conducting behavioral health and mental health biopsychosocial assessments.
• Making sound professional judgments regarding clinical impressions, treatment approaches, and treatment/care planning.
• Coordinating with internal and external professionals to ensure appropriate transitions of care and appropriate/necessary treatment is provided/offered to Veterans.
• Establishing and maintaining knowledge of VA and Veteran's benefits and services, community resources, and process for making appropriate referrals to community and other governmental programs or agencies.
• Providing advocacy to overcome potential barriers to access care/services and when it is in the best interests of the Veteran.
• Providing goals of care discussions, as well as education and assist in the completion of Advance Directives; Organ, Tissue, and Eye Donation release of information forms; and Guardianship documentation.
• Assessing for signs and symptoms of abuse, neglect and exploitation.
• Conducting practice in accordance with the VA and discipline specific ethical requirements and practices within the limits of current licensure or certification.
• Completing on-call duties, as assigned and per policy, which may include transportation of a Veteran.

Administrative Functions:

• Possesses and demonstrates ability to communicate effectively, both orally and in writing with people from varied backgrounds.
• Possesses skills in using computer systems and the internet for Veterans who choose this modality to communicate.
• Serves on supervisor approved committees, work groups, and task forces at the local facility, VISN or national level. Collaborates in performance improvement processes and complies with performance measures as required by the VA for specific population/program.
• Attends and participates in all required administrative and clinical meetings.
• Maintains accurate, timely, and complete clinical records in accordance with professional practice and VA administration guidelines.
• Maintains data and statistical compilations to comply with accreditation bodies such as CARF and Joint Commission, and VA health care systems policies and procedures.
• Participates in Social Work Professional Practice Evaluation processes.
• Performs other duties as assigned and can, at times, assist other incumbents or perform special assignments to meet the needs of the healthcare system. The incumbent may be assigned to other areas of need in the health care system, as determined necessary by the direct supervisor and/or the Integrated Care Community (ICC) Director in consultation with the Social Work Executive.

Role-Specific Tasks:

• Independently treat Veterans and their families who are experiencing a wide range of complicated medical, psychiatric, emotional, behavioral, financial, legal and psychosocial problems.
• The incumbent is able to assess functional acuity of the Veteran and provide appropriate interventions, including psychosocial treatment, supportive therapy, including brief individual, group, and family therapy, and case management.
• Ability to coordinate efforts for community placements by working closely with Veterans, their families, and interdisciplinary treatment teams to ensure that suitable community placements are completed efficiently.
• Conduct Virtual Visits in modalities preferred by patients and utilize Consult Toolbox functions.

Work Schedule: Monday-Friday 8am-4:30pm

Telework: Not Available

Virtual: This is not a virtual position.

Relocation/Recruitment Incentives: Not Authorized

Permanent Change of Station (PCS): Not Authorized