The Senior Social Worker (Home Based Primary Care) is responsible for assessment, planning, and provision of case management services in the HBPC Program. The Senior Social Worker offers consultation to colleagues and students on the psychosocial treatment of patients in The Home Based Primary Care Program rendering professional opinions based on experience and expertise and role modeling effective social work practice skills. The Senior Social Worker: develops an assessment of the veteran in collaboration with the interdisciplinary treatment team, the veteran, and family members/significant others, whenever possible. The goal of the assessment is to highlight the veteran's strengths, limitations, and internal/external supports and service needs in order to optimize the veteran's functional status and safely maintain the veteran in his/her home. The assessment will include a home visit. completes the Suicide Risk Assessment shared template in the Computerized Patient Record System (CPRS) on all patients with suicidal ideation and on any patient whose record is flagged "High Risk for Suicide." contributes to the development of the treatment plan and setting achievable treatment goals with the veteran, family members/significant others and other HBPC clinical staff. is the subject matter expert on VA and/or community resources. collaborates with other service providers in reassessing the veteran's needs for non-institutional, institutional services/programs and entitlements. educates the veteran and families/significant others of the available services and assisting them in establishing the appropriate referrals based on the veteran's preference or that of his surrogate decision-maker. utilizes the current Social Work resource file of VA and community social service programs and enhancing the content to the benefit of veterans. refers veterans to needed services. understands the intimidation of bureaucracy and will act as an advocate when it serves the best interest of the veteran and family members/significant others. (when appropriate and feasible) educates and encourages the veteran to advocate on his/her own behalf, thus fostering a sense of independence and empowerment. makes rapid assessments and developing crisis management plans. has access to multiple resource directories in addition to previously developed resources to meet the demands of a crisis. In the event of a medical or psychiatric emergency, the Social Worker will follow the established protocol for the HBPC Program and TVCBHCS. provides education related to VA and community resources, entitlements, Advance Directives/Living Will and will refer veterans and families/significant others to the appropriate interdisciplinary team member for identified health education needs. coordinates referrals for non-institutional services such as Respite, ADHC/CADHC, home hospice and skilled and non-skilled homecare services in collaboration with the interdisciplinary treatment team members. coordinates referrals of institutional placements in Adult Homes, Assisted Living Programs, CNH or VA-NHCU. This includes reviewing the progress notes from the other providers to accurately determine the strengths and limitations of each veteran being referred for non-institutional and institutional alternatives. educates veterans, their family members/significant others and the team of all the options available to them and collaborates with the veteran and family members/significant others on the preferred option. provides veterans and their caregivers with ongoing supportive counseling. The purpose of such counseling is to deal with the psychosocial impact of coping with chronic/disabling illness (es), onset of a catastrophic illness and need for non-institutional or institutional services, as needed, during the course of the veteran's enrollment in the HBPC Program. enters all veteran/family contacts in the electronic record using appropriate formats and templates. This information will be entered in a complete, confidential, and professional manner to insure information on the veteran is shared with other VA staff. This information will be reviewed on a regular basis. establishes and maintains positive working relationships with employees, volunteers, consumers and stakeholders within the VA and outside community agencies. attends all appropriate staff meetings (i.e. team meetings, Social Work staff meetings, Social Work supervision meetings, committee meetings, workgroups, etc., as appropriate). collaborates in the performance improvement processes and comply with performance measures as required by the VA for their specific population and/or program. participates in activities that obtain feedback from clients and work to enhance services as needed. uses the social work process (psychosocial assessment, diagnosis, and treatment) to conduct an intake health status assessment or an update assessment for OEF/OIF/OND veterans. utilizes clinical reminders to evaluate the need for health care, behavioral and mental health services. makes appropriate referrals for health care, individual, group, marital and/or family treatment services. Informs the OEF/OIF program support assistant when an intake health status assessment is initially completed for an OEF/OIF/OND Veteran. Work Schedule: Monday - Friday: 8 AM - 4:30 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.