The incumbent serves 50% of the time as an integral member of the Home Based Primary Care Team (HBPC) to outpatient home bound Veterans served by this medical center (Altoona VAMC). Clinical social work services are based on bio-psychosocial interactions, intrapsychic dynamics, and life management issues. The incumbent will serve the other 50% as an integral member of the Primary Care Patient Aligned Team (PACT) to outpatient Veterans served by this medical center. The incumbent is responsible for independently assuring that Central Office Geriatrics and Extended Care program standards/policies and VHA Directive 1411 Home Based Primary Care Special Population PACT Team are adhered to in an effective and efficient manner. In addition the incumbent is duties will consist of : The incumbent independently conducts psychosocial assessments, within program prescribed timeframes, to include the Veteran's strengths, limitations, internal/external supports, and service needs in order to optimize the Veteran's functional status and safely maintain the Veteran in their preferred living situation. The incumbent develops and implements realistic and achievable psychosocial treatment plans and goals as part of the HBPC/PACT treatment plans reflecting effective utilization of a broad range of treatment modalities and interventions. The incumbent further possesses the skills to measure outcomes of provided psychosocial interventions. The incumbent applies a working knowledge and experience in use of medical and mental health diagnoses, disabilities and treatment procedures for acute, chronic, and traumatic illness/injuries, common medications including their effects and side effects, non-pharmacological pain interventions, stress management, and, medical terminology. The incumbent applies knowledge of social determinants of health to the assessment of need and risk. The incumbent evaluates the acuteness of need for psychosocial intervention and case management services based on high risk factors such as suicide, intimate partner violence, adult abuse/neglect, food insecurity, homelessness, terminal illness, competency/guardianship, and other acute psychosocial stressors. The incumbent identifies the need for adaptive equipment and works with the interdisciplinary team to coordinate. The incumbent assesses for home health and non-institutional care needs. Assessments identify psychosocial issues impacting the patient/caregiver's ability to achieve optimal outcomes and implementing interventions. Based upon the assessment, social work case management addresses psychosocial needs and supports patient driven goals of care. Other duties as assigned Work Schedule: M-F 8:00am-4:30pm 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.