Caseworker/Mental Health Clinics

Job Title

Social Worker

Job Description

The Patient Aligned Care Team (PACT) is a comprehensive, interdisciplinary model designed to provide longitudinal, Veteran-centered primary care with an emphasis on prevention, health promotion, chronic disease management, and care coordination. Within this framework, the social worker functions as an essential care coordinator for an assigned panel of Veterans, ensuring that care aligns with each Veteran's individual needs, goals, and values. Social workers apply advanced clinical skills, and a holistic perspective rooted in the person-in-environment framework to address the full spectrum of biopsychosocial factors influencing Veteran health outcomes. Must have a high level of skill and expertise to establish and maintain effective therapeutic relationships with Veterans in the Primary Care Clinic and/or their families. The incumbent can independently work with Veterans and their families who are experiencing a wide range of complicated medical, psychiatric, emotional, behavioral, financial, legal, and psychosocial problems. Effective social work in the Patient Aligned Care Team context often occurs over a series of several visits and may involve the need of the social worker to visit the Veteran in their home. Independently complete comprehensive, strengths-based psychosocial assessments, incorporating Veteran self-identified concerns and the impact of family, community, housing, and environmental factors. Assess and monitor changes in psychosocial functioning, financial status, housing, food security, and caregiver burden, updating assessments as clinically indicated. Provide case management services across the continuum of care, including coordination of medical, mental health, and community-based services. Apply knowledge of human development across the lifespan to address issues of disability, terminal illness, loss, and grief. Serve as an active member of the interdisciplinary PACT team, collaborating with primary care providers, nurses, pharmacists, behavioral health staff, and specialty Social Workers to develop and implement person-centered care plans. Provide ongoing consultation to team members regarding psychosocial barriers to care and facilitate problem-solving strategies to promote treatment engagement and adherence. Implement evidence-based treatment modalities and therapeutic interventions as appropriate, including psychoeducation, supportive counseling, crisis intervention, and behavioral activation strategies. Conduct diagnostic assessments and psychotherapy under the supervision of an LCSW supervisor, as appropriate to level of licensure. Must understand caregiver stressors, ability to conduct caregiver assessment and provide appropriate caregiver specific interventions. Facilitate timely and appropriate referrals for community placements such as assisted living, group homes, adult day health care, home health, hospice, and nursing home care. Serve as a liaison between the VA, Veterans, caregivers, and community agencies to ensure continuity of care and access to services. Educate Veterans and families on VA and non-VA benefits, community resources, advance directives, and health system navigation.