| This position is eligible for the Education Debt Reduction Program (EDRP), a student loan payment reimbursement program. You must meet specific individual eligibility requirements in accordance with VHA policy and submit your EDRP application within four months of appointment. Approval, award amount (up to $200,000) and eligibility period (one to five years) are determined by the VHA Education Loan Repayment Services program office after complete review of the EDRP application. Learn more A Recruitment/Relocation Incentive may be available for highly qualified applicants The Senior Social Worker functions as a primary contact for community agencies, hospitals, health care facilities, city and county governments, providing general information about VA benefits & eligibility and the VA Palo Alto Health Care System. Duties to include, but not limited to; Coordinates and provides information in compliance with HIPAA and VA Privacy regulations regarding VA benefits pertaining to nursing home care, in-home assistance, and Aide and Attendance/housebound benefits Evaluates Veterans' eligibility for VA nursing home care and identifies the medical needs to distinguish between extended care services, other VA inpatient programs, Medi-Cal long term care options, in-home health services and county services. Incumbent facilitates communication between outside hospitals and VA Modesto CBOC primary care providers Develops, adapts and directs social work services to meet the changing needs of the Integrated Primary Care and Mental Health Clinics and any specialty clinics at VA Livermore Division while engaging the I-PACT Teamlets to work with patient and family to address bio-psycho-social needs Serves as a leader for I-PACT Medical Social Worker at the Livermore Division for advanced knowledge of VA and Community resources, consultation regarding difficult cases when the supervisor is not available and offering regular competency trainings to I-PACT SW Section and Staff Responsible for tracking and managing I-PACT Livermore and off-site medical social work consults and troubleshooting data management (e.g. encounter/documentation concerns to monitor and maintain appropriate productivity) Responsible for tracking and coordinating timely completion of Goals of Care Discussions, POLST and Advance Directives as well as coordinating Advance Care Planning Patient Education Groups, Long Term Care Planning Education Groups, Resource Groups, and Grief Groups. Incumbent will also cross cover Mental Health Groups as needed and may also participate in coordinating the New Patient Orientation Education Group with the interdisciplinary team members Coordinates medical social work services including referrals to community resources and provides support services in these areas to the mental health clinic and serves as an advocate for Veterans while addressing system and psychosocial barriers to care to track opportunities for quality improvement that should be tracked and adapted to improve processes Coordinates long term care referrals to VA Community Living Centers (CLC) at Menlo Park and/or Livermore and facilitates long term care referrals to contracted nursing homes with the Community Nursing Home Coordinator Coordinates referrals to Homemaker, Home Health Aide (H/HHA), Adult Day Health, Inpatient Respite Program, and first conducts functional assessments to assess patient eligibility for the services and communicates with family and service providers about options increasing custodial care in the home Collaborates with H&CBC nurses and assists CBOC IPACTs with home health referrals to provide continuity of treatment for patients requiring skilled care in their homes. Incumbent has working knowledge of requirements for home skilled service consults and provides support to PACTs with Home Skilled Service consults as well as OT home safety evaluations Manages and coordinates home Hospice referrals through consultation with primary care providers. Assists with education of patient and family about pre-hospice services available in local counties, home hospice services through Medicare, private insurance or fee basis, VA inpatient hospice services, and the concept of Palliative and Hospice Care Coordinates with Primary Care Providers to develop and improve efficient and effective ways of providing education and assistance to patients related to Goals of Care, Advance Directives and Life Sustaining Treatment. Manages Advance Health Care Planning education, assistance with completion, scanning and filing of document Performs direct clinical work at the advance practice level, demonstrating specialized knowledge and expertise in the assessment, planning and implementing of interventions for the spectrum of problems encountered in an outpatient mental health clinic Provides case consultation and clinical case management on complex, difficult, multi-factorial cases involving Veterans with multiple medical, psychological and social issues that complicate the management of their healthcare Directs provision of social work services to Veterans and their families, provides consultation services to medical and mental health providers regarding services, resources and interventions Other duties as assigned |
