Social Worker-Home Based Primary Care

About the role

The Social Worker provides Veterans in the Home‑Based Primary Care (HBPC) Program with high‑quality case management, clinical treatment, advocacy, and coordination of services with VA and community providers. Services include psychosocial assessment of Veterans and families, individual/group/family counseling, caregiver burden assessments and interventions, and casework to address identified needs.

Responsibilities

• Develop and conduct comprehensive psychosocial assessments in collaboration with the interdisciplinary team, Veterans, families, and significant others.
• Create treatment plans and set achievable goals with Veterans and families, aligning with HBPC policies and procedures.
• Serve as a subject‑matter expert on VA and community resources; educate Veterans and caregivers about available services and assist with referrals.
• Maintain a resource file of VA and community social service programs and coordinate referrals to non‑institutional services (e.g., Adult Day Health Care, home hospice, skilled and non‑skilled home care).
• Provide advocacy, encouraging Veterans and families to act on their own behalf to foster independence.
• Perform rapid crisis assessments and develop crisis management plans to keep patients safely at home or arrange appropriate placements.
• Educate Veterans and families on entitlements, advanced directives, durable powers of attorney, and Physician Orders for Life‑Sustaining Treatment.
• Facilitate complex care reviews or family conferences with the interdisciplinary team and external providers.
• Offer ongoing supportive counseling to Veterans and caregivers.
• Participate in HBPC quality‑assurance activities, including data collection, analysis, and system‑improvement planning.
• Conduct community nursing‑home visits to assess psychosocial needs and adequacy of care.

Requirements

Basic Requirements

• U.S. citizenship (non‑citizens may be appointed only when qualified citizens cannot be recruited).
• Proficiency in spoken and written English as required by 38 U.S.C. 7403(f).

Education

• Master’s degree in Social Work from a Council on Social Work Education (CSWE)‑accredited school. (Doctoral degree cannot substitute for the master’s.)
• Verification of accreditation can be made at http://www.cswe.org/Accreditation.

Licensure

• State license or certification to independently practice social work at the master’s level.
• VHA may waive licensure for GS‑9 candidates pending completion of state prerequisites; licensure is required for GS‑11 and above.
• Unlicensed/uncertified hires must receive written licensure requirements and timelines from the supervisor.
• Failure to obtain or maintain a valid license results in removal from the GS‑0185 series and possible termination.

Grade Determinations

• GS‑9: No experience beyond basic requirements; must demonstrate KSAs listed below.
• GS‑11: Minimum one year of post‑MSW experience equivalent to GS‑9 in health‑care or related social‑work settings, plus licensure; a doctoral degree may substitute for the experience requirement.

Knowledge, Skills, and Abilities (KSAs)

• Ability to work with Veterans and families from diverse socioeconomic, cultural, and ethnic backgrounds using counseling skills.
• Skill in assessing psychosocial functioning, identifying problems, strengths, coping skills, and needed assistance, and formulating treatment plans.
• Proficiency in implementing treatment modalities (supportive, problem‑solving, crisis intervention) for individuals, families, and groups.
• Effective communication and relationship‑building with clients, staff, and community agency representatives.
• Fundamental knowledge of medical and mental‑health diagnoses, disabilities, treatment procedures, common medications, side effects, and medical terminology.
• Knowledge of community resources and ability to make appropriate referrals and coordinate services.
• Capability to provide consultation to new social workers, graduate students, and other staff regarding psychosocial needs and their impact on health care.

Physical Requirements

• Moderate lifting (under 15–44 lb) and carrying (15–44 lb).
• Use of fingers and operation of a motor vehicle.
• Work in environments with slippery or uneven walking surfaces, moving objects or vehicles, and close collaboration with others.

Pay

Competitive salary with regular salary increases; higher step rates may be awarded based on unique qualifications or special VA needs (above minimum grade rate).

Schedule

Monday through Friday, 8:00 am – 4:30 pm.

Benefits

• Annual paid time off: 37–50 days (13–26 days annual leave, 13 days sick leave, 11 federal holidays).
• Parental leave: Up to 12 weeks paid after 12 months of employment for birth, adoption, or foster care placement.
• Child‑care subsidy: Up to 25 % of eligible costs (maximum $416.66 per month) for full‑time employees with family income below $144,000 after 60 days of employment.
• Retirement: Traditional federal pension (5‑year vesting) and federal 401(k) with up to 5 % VA contributions.
• Insurance: Federal health, vision, dental, term life, and long‑term care coverage (portable into retirement).
• Telework: Not available.
• Virtual: Not a virtual position.