Social Worker - Home Based Primary Care

About the role

The Incumbent provides social work services for Veterans enrolled in the Home-Based Primary Care program. In-home social work services are provided for Veterans with a wide variety of multiple, complex chronic illnesses and/or profound disabilities. The position involves regular independent travel to patients' homes. Services provided include provision of quality case management, clinical treatment, advocacy, and coordination of linkages to other appropriate VA or community service providers.

Responsibilities

• Independently uses advanced practice skills to make a psychosocial diagnosis of needs based on the assessment.
• Collaborates with the HBPC team in the development of the interdisciplinary team plan of care, works effectively with the HBPC team and other health care providers in coordinating the patient's total care, and maintains professional relations and communications with Veterans, caregivers, VA and community health care professionals, and the public.
• Participates in required interdisciplinary team and Social Work conferences, huddles, and meetings.
• Educates the Veteran and/or caregiver of VA and non-VA services and resources. Advocates for Veterans and their families, helping them access the services needed at the facility, at other VA facilities, and in the community.
• Documents clinically significant information from assessments and interventions with the Veteran, family or significant other in the electronic record using assigned formats and templates, according to HBPC and Medical Center policy and JC standards.
• Maintains and documents data regarding patient visits and other key factors in approved databases. Collaborates in the performance improvement process and complies with performance measures as required by the VA, program, and Medical Center.
• Develops effective partnerships with internal and external customers, including local, state and federal agencies as well as non-governmental organizations. Maintains positive working relationships with employees, volunteers, consumers and stakeholders within the VA and outside community agencies.
• Participates effectively in team meetings, treatment planning conferences, etc. Collaborates with divergent multidisciplinary team members in a manner that enhances coordination of comprehensive patient care.
• Effectively communicates with and utilizes community agencies to facilitate treatment, discharge planning, and continuity of care. Gives evidence of having regular contact and interaction with a variety of community agencies and resources.
• Relationship with supervisors, co-workers, patients, visitors, and the general public is consistently courteous and cooperative in nature and overall contributes to the effective operation of the implementation of Social Work services to the veteran population.
• Complies with federal, state, and local environmental and other requirements preventing pollution, minimizing waste, and conserving cultural and natural resources.
• Uses word processing software to execute several office automation functions such as storing and retrieving electronic documents and files; activating printers; inserting and deleting text, formatting letters, reports, and memoranda; and transmitting and receiving e-mail; and utilizing computerized virtual fax capabilities.
• Operates a government-owned/leased vehicle to properly carry out assigned duties. Must possess and maintain a valid, unrestricted State driver's license, have a safe driving record, and demonstrate that they are medically qualified to operate the appropriate motor vehicle safely.

Qualifications

• Education: Have a master's degree in social work from a school of social work fully accredited by the Council on Social Work Education (CSWE).
• Licensure: Persons hired or reassigned to social worker positions in the GS-0185 series in VHA must be licensed or certified by a state to independently practice social work at the master's degree level.
• Experience: Appointment to the GS-11 grade level requires completion of a minimum of one year of post-MSW experience equivalent to the GS-9 grade level in the field of health care or other social work-related settings, (VA or non-VA experience) and licensure or certification in a state at the independent practice level.