Social Worker (Home-Based Primary Care)

About the role

Provides Veterans in the Home‑Based Primary Care (HBPC) Program with high‑quality case management, clinical treatment, advocacy, and coordination of linkage with appropriate VA and community service providers and agencies as needed. Services include psychosocial assessment of Veteran and family needs; individual, group, and family counseling; caregiver‑burden assessments and intervention; and casework services to address identified needs.

Responsibilities

• Screening Assessment: Develop an assessment of the Veteran in collaboration with the interdisciplinary treatment team, the Veteran, family members, and significant others whenever possible.
• Treatment Planning & Goal Setting: Create treatment plans and set achievable goals with the Veteran and family in partnership with the HBPC interdisciplinary team.
• Follow policies and procedures of Home & Community Based Services (HCBS)‑HBPC and the Medical Center, ensuring proper patient‑rights documentation, progress notes, outcomes, discharge planning, and treatment plan maintenance.
• Referral to Service Providers: Serve as a subject‑matter expert on VA and community resources, collaborating with other providers to reassess Veteran needs for non‑institutional and institutional service programs and entitlements.
• Resource Development: Compile and maintain a resource file of VA and community social service programs and refer Veterans to needed services.
• Advocacy: Educate and encourage Veterans and families to advocate on their own behalf, fostering independence and empowerment.
• Crisis Intervention: Conduct rapid assessments and develop crisis‑management plans to keep patients safely at home or arrange appropriate acute, short‑term, or long‑term placements.
• Provide education on VA and community resources, entitlements, advanced directives, durable power of attorney, and Physician Orders for Life‑Sustaining Treatment, referring Veterans/families to interdisciplinary team members for health‑education needs.
• Facilitate complex‑care reviews or care/family conferences to coordinate interdisciplinary planning for Veterans with complex needs.
• Coordinate referrals for non‑institutional services such as Adult Day Health Care, home hospice, skilled and non‑skilled home‑care services.
• Offer ongoing supportive counseling to Veterans and their caregivers.
• Participate as a member of the HBPC Quality Assurance team, including data collection, analysis, system‑improvement planning, and re‑evaluation of plan success.
• Conduct community nursing‑home visits to assess psychosocial needs of Veterans and the adequacy of care/services provided.

Qualifications

• U.S. citizenship (non‑citizens may be appointed only when qualified citizens cannot be recruited in accordance with VA policy).
• Master’s degree in Social Work from a Council on Social Work Education (CSWE)‑accredited school; doctoral degree may substitute for required post‑MSW experience at the GS‑11 level.
• State licensure or certification to independently practice social work at the master’s level (waiver possible at GS‑9 pending completion of state prerequisites; required for GS‑11 and above).
• Proficiency in spoken and written English as required by 38 U.S.C. 7403(f).
• Demonstrated KSAs for GS‑9: veteran‑centric counseling, psychosocial assessment, treatment‑plan formulation, implementation of supportive/problem‑solving/crisis‑intervention techniques, effective communication with clients, staff, and community agencies, and fundamental knowledge of medical and mental‑health diagnoses, medications, and terminology.
• Additional KSAs for GS‑11: knowledge of community resources and referral processes, independent psychosocial assessments and interventions, formulation of treatment plans for diverse populations, consultation to new social workers and staff, and ability to coordinate interdisciplinary care.

Physical Requirements

Moderate lifting and carrying (15‑44 lb), use of fingers, and operation of equipment such as cranes, trucks, tractors, or motor vehicles. Work environments include indoor and outdoor settings with slippery or uneven surfaces, moving objects, and close collaboration with others.

Schedule

Monday‑Friday – 8 am to 4:30 pm

Pay

Competitive salary with regular salary increases; a higher step rate may be awarded based on superior qualifications or special VA needs.

Benefits

• Paid Time Off: 37–50 days annually (13–26 days annual leave, 13 days sick leave, 11 Federal holidays); credit toward annual leave may be granted for prior work or military service.
• Parental Leave: Up to 12 weeks paid leave after 12 months of employment for birth, adoption, or foster care placement.
• Child‑Care Subsidy: After 60 days, eligible full‑time employees with family income below $144,000 may receive up to 25 % of eligible child‑care costs, capped at $416.66 per month.
• 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; many programs are portable into retirement.
• Telework: Not available.
• Virtual: Not a virtual position.
• Recruitment Incentive (Sign‑on Bonus): Not authorized.
• Permanent Change of Station (Relocation Assistance): Not authorized.