The Senior Social Worker is responsible for providing clinical case management to adult and geriatric veterans assigned to the GeriPACT clinic. This population has serious health, mental health and crisis needs and may lack familial and community support, be poor self-monitors, fail to adhere to treatment and/or have major deficits in coping skills requiring continuing formal support. The incumbent works collaboratively with medicine and specialty clinics to further the VA mission in providing exceptional health care to improve the health and well-being of veterans The incumbent is responsible for assisting veterans, families and significant others cope with the crisis of illness, maximizing interpersonal and social functioning, providing education to veterans and interdisciplinary team members on the psychosocial impact of illness and disease progression. The incumbent ensures the plan of care addresses, in an interdisciplinary manner, the biopsychosocial status of severely disabled, frail, and/or older persons at risk for further decline and institutional placement, with the intention of optimizing their health, function and ability to live with the greatest degree of independence suitable for their situation. The incumbent coordinates communication with veterans, families or significant others including appropriate team members to facilitate effective communication of the team plan. The incumbent develops a system to identify and educate staff regarding Veterans who will benefit from the program. This involves use of the Patient Treatment File searches, Veterans Health Information System, and Technology Archive (VISTA) and Computerized Patient Record System (CPRS). The incumbent develops a plan to identify potential problems with the GeriPACT program and works with quality management staff to ensure that national guidelines are met. The incumbent participates in the daily operation of the GeriPACT and provides accountability for program effectiveness and modification of service patterns to enhance customer satisfaction. The incumbent address Advance Directives, Organ Donation, Guardianship/Fiduciary status and Goals of Care conversations in accordance with the standards of the work area. The incumbent will provide wellness/prevention education and facilitate Patient/family support groups as appropriate. 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. Documentation will be completed promptly and accurately per policy and/or procedures. The incumbent will ensure appropriate hand off when transferring patient care. The incumbent offers consultation to colleagues, social work students, residents, interns, and fellows from other disciplines regarding the psychosocial treatment of patients, rendering professional opinions based on experience and expertise and role modeling effective social work practice skills. The incumbent demonstrates the ability to teach and mentor staff and students in the special area of practice and to provide supervision for licensure or specialty certifications. Incumbent participates and prepares reports and statistics for facility, VISN, and national use. The incumbent utilizes data regarding day-to-day functioning and program evaluation. The incumbent ensures the GeriPACT program is in compliance with VHA directives and care is rendered pursuant to the guidance of Clinical Practice Guidelines. 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 incumbent may be required, at times, to work an irregular tour of duty depending on the needs of the service. Work Schedule: Monday to Friday, 8am to 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.