Social Worker

Social Worker

Duties of the Social Worker are to include, but not limited to: Screening/Assessment - In conjunction with the interdisciplinary treatment team, the HBPC Social Worker screens, assesses and addresses the Veteran's psychosocial needs and barriers in order to provide care management to Veterans as they reside in their homes. Through collaborative relationships with the Veteran, his or her family/caregiver and other VA programs and VA staff, the HBPC Social Worker coordinates the gathering of information vital to the process of completion of the psychosocial portion of the interdisciplinary care plan.

Treatment Planning/Goal Setting - From screening/assessment information, the HBPC Social Worker, in collaboration with the interdisciplinary team, determines realistic goals that consider such factors as a) safety in the home, b) transportation options/barriers, c) financial resources, d) caregiver/family supports and e) the steps to obtaining resources (VA or community) that ensure that the Veteran can maintain in their home as long as possible.

Advance Directive Screening and completion - The HBPC Social Worker will screen Veterans to identify the need to provide education and offer assistance with completing an advance directive.

Referral to service providers - To facilitate the continuity of a Veteran's recovery and enhance their ability to stay in their homes, the HBPC Social Worker will arrange referrals to needed VA and/or community resources (e.g., home health care, services available through area agencies on aging, community support groups, hospice care, Adult Day care, respite, etc.) The HBPC Social Worker will educate the Veteran and/or caregiver about the available services and their shared responsibility in accessing such services. The Veteran's preferences or that of his/her surrogate decision-maker will be considered throughout the referral and care coordination process.

Resource Usage/Development - As a developing subject matter expert on the services and resources available to Veterans through both VA and the community, the HBPC Social Worker will monitor patterns of resource availability, identifying unmet needs and gaps in service delivery. The HBPC Social Worker will communicate with appropriate stakeholders (e.g., the SW Supervisor/Program Coordinator of Community Based Extended Care, the Social Work Chief, the Social Work Professional Practice Council, other VA programs, community partners) to encourage the development of new and innovative resources.

Advocacy - The HBPC Social Worker will advocate for the Veteran to ensure that he or she has access to all needed care and resources within VA and in the community. By availing the Veteran of his or her choices in complex decisions and by guiding the Veteran through complicated enrollment procedures and bureaucratic processes, the HBPC Social Worker facilitates the best possible outcome for the Veteran. When appropriate and feasible, the HBPC Social Worker will educate and encourage the Veteran and his/her family/caregiver to advocate on his/her own behalf, fostering independence and empowerment.

Crisis Intervention - The HBPC Social Worker will assess and intervene in any medical or psychiatric crises presented by the Veteran and participate in developing crisis management and safety plans to minimize the event of future crises. The HBPC Social Worker will work collaboratively with other disciplines on complex cases (i.e. the Psychiatry Consultation Team).

Work Schedule: Monday-Friday 7am-3:30, 7:30am to 4pm, or 8am-4:30pm, No Weekends/Holidays, No on-call

Compressed/Flexible: Not available

Telework: Available

Virtual: This is not a virtual position.

Functional Statement #: 91796-0, 91797-0

Relocation/Recruitment Incentives: Not Authorized

Financial Disclosure Report: Not required

Travel: Regular, occasional travel required (within your work schedule); must possess a valid drivers license and be able to operate a government owned vehicle