Social Worker-Home Based Primary Care (HBPC)

Summary

*Recruitment Incentive Authorized*

Responsibilities

• Develops an assessment of the Veteran in collaboration with the interdisciplinary treatment team, the Veteran, and family members/significant others, whenever possible.
• Contributes to the development of the treatment plan and sets achievable treatment goals with the Veteran, family members/significant others, and other HBPC/Specialty PACT clinical staff.
• Collaborates with other service providers in reassessing the Veteran's needs for non-institutional, institutional services/programs and entitlements.
• Develops a resource file of VA and community social service programs and enhances the content to the benefit of Veterans.
• Acts as an advocate when it serves the best interest of the Veteran and family members/significant others.
• Makes rapid assessments and develops crisis management plans, accessing multiple resource directories to meet the demands of a crisis.
• Provides education related to VA and community resources, entitlements, Advance Directives/Living Wills, and refers Veterans and families/significant others to the appropriate interdisciplinary team member for identified health education needs.
• Coordinates referrals of non-institutional services such as HBPC, 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 Foster Homes, Medical Foster Homes, Assisted Living Programs, CNH, or VA CLC.
• Provides ongoing supportive counseling to Veterans and their caregivers.
• Enters all Veteran/family contacts in the electronic record using appropriate formats and templates, ensuring information is shared with other VA staff in a complete, confidential, and professional manner.

Qualifications

• Master's degree in social work from a CSWE-accredited school.
• Licensed or certified by a state to independently practice social work at the master's degree level.
• Knowledge of medical and mental health diagnoses, disabilities, and treatment procedures.
• Ability to utilize a Veteran-centric approach in interventions and counseling.
• Ability to assess psychosocial functioning and needs of Veterans and their family members, and to formulate and implement a treatment plan.
• Ability to establish and maintain effective working relationships and communicate with clients, staff, and representatives of community agencies.