The social worker is assigned to the Carl Vinson VAMC, Milledgeville Community Based Outpatient Clinic (CBOC), HBPC Program with responsibility to provide direct services for adult and geriatric veterans enrolled in this program. This position is clinically and administrative responsible to the HBPC Coordinator. The incumbent is responsible for assessment, planning, and provision of case management services in the HBPC Program. This professional social worker coordinates a variety of activities including outreach, interdisciplinary activities, psychosocial assessments, treatment planning, consultation/education to Medical Center staff and community based service providers, the collection and maintenance of statistical data, program planning evaluation and modification, and the supervision of students as assigned The incumbent is responsible for completing psychosocial assessments to determine needs of veterans and family members. He/she is an active participant in the treatment planning process with other disciplines. The incumbent will participate in discharge planning with other disciplines and will be responsible for ensuring that discharge plans are executed in a manner that is timely and appropriate. The social worker will provide individual, family and group counseling as appropriate. The incumbent will provide consultation/education to veterans and families on community resources, advance directives and VA benefits. He/she will act as a consultant to other team/staff members. The social worker will provide case management to veterans and families, as needed, throughout the continuum of care. The incumbent will provide a full range of social work services within commonly accepted standards of social work practice which includes case work, individual, family and group counseling, discharge planning, case management and other services as appropriate. He/she will address Advance Directives in accordance with the standards of their work area. The incumbent will provide wellness/prevention education and facilitate Patient/family support groups as appropriate and coordinate treatment and communicate with the care lines to facilitate continuity of care for veterans. In addition, the incumbent will assist patients and their significant others with coping and dealing with the loss and grief experiences in disability, terminal illness and death. The incumbent will document social work interventions and activities in patient's clinical record utilizing CPRS and ensure appropriate hand off when transferring of patient care. ADMINISTRATIVE FUNCTION As a member of the Interdisciplinary Treatment Team in the HBPC Program, the individual conducts work activity independently using his/her educational training, clinical experience, VA policies, and Joint Commission standards in administering direct services: psychosocial assessment of patient/family needs in relation to the provision of interdisciplinary treatment planning and service delivery; individual, group, and family counseling and casework services for the purpose of addressing identified needs. The incumbent must have knowledge of community based resources. The social worker will provide services both via telephone contact and in the homes of veterans enrolled in HBPC. The social worker will collaborate with the other members of the HBPC team in the provision of comprehensive health care services to HBPC veterans, will ensure equity of access, service, and benefits to this population, and collect, develop and analyze data from this program, using appropriate clinical indicators and monitoring activities to assure that the care provided is of the highest quality. The social worker will conduct training for staff, students and community providers regarding HBPC issues, will provide education, information and liaison with resources for veterans in the community, and will provide technical assistance and educational sessions to community organizations as needed. The incumbent is responsible for the implementation of written treatment program policies and procedures developed by Social Work Service that are based on coherent empirical and theoretical rationale and are consistent with patient rights and the maintenance of comprehensive written patient progress notes, outcomes and discharge planning services in collaboration with the unit treatment team. He/she will act as liaison between VA and community resources, to include marketing and public relation duties as needed. The incumbent will maintain data and statistical compilations to comply with JCAHO, VA and medical center policy and procedures. Other duties and responsibilities may be assigned by the team/group leader as needed for the benefit of the veteran, family, and quality of services provided. The individual works in HBPC and may coordinate other needed services for HBPC patients including Home Health Aide and Adult Day Health Care. Work Schedule: M-F 7:00 am - 4:00 pm 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.