The incumbent provides Veterans that have been seen in the community for ER care or unplanned inpatient admission with high quality case management, advocacy and care coordination with appropriate VA and Community Care service providers as needed by the client. This is accomplished in collaboration with the primary care or community care interdisciplinary teams as appropriate. Duties of this position include, but are not limited to, the following: Completes an assessment of the Veteran, family, economic, community, and psychosocial support systems when clinically indicated. Assists Veterans and families with assessing for supportive services such as Home maker Home Health Aide services, nursing home or assisted living placement and other community resources. Demonstrates basic knowledge of psychosocial treatment modalities and demonstrates the ability to implement treatment modalities in working with individuals, families, and groups to achieve treatment goals. Develops a treatment plan and setting achievable treatment goals with the Veteran/family in collaboration with the primary care interdisciplinary treatment team members when indicated. Collaborates with other service providers in reassessing the veteran's needs for VA and community resources and entitlements. Develops a resource file of VA and community social service programs and will refer the Veteran to needed services. Develops crisis management plans to maintain patient in the home, for admission to acute, short term and/or long-term placements. Provides the Veterans and their caregivers with ongoing supportive counseling. Enters all Veteran/family contacts in the electronic record using appropriate formats and templates. Work Schedule: Monday through Friday, 8:00 am to 4:30 pm. Telework: Not Available. Virtual: This is not a virtual position. Position Title/Functional Statement #:Social Worker/PD000000 Relocation/Recruitment Incentives: Not Authorized. Permanent Change of Station (PCS): Not Authorized. Financial Disclosure Report: Not required.
Providing Health Care for Veterans: The Veterans Health Administration is America’s largest integrated health care system, providing care at 1,255 health care facilities, including 170 medical centers and 1,074 outpatient sites of care of varying complexity (VHA outpatient clinics), serving 9 million enrolled Veterans each year.