The Clinical Social Worker in this position provides direct services to adult and geriatric Veterans enrolled in the Home Based Primary Care (HBPC) Program/Specialty PACT with high quality case management, clinical treatment, advocacy, and to coordinate linkage with appropriate VA and community service providers / agencies as needed by the client. This is accomplished in collaboration with other members of the HBPC Team or other interdisciplinary treatment teams as appropriate. This position is responsible for assessment, planning, and provision of case management services in the HBPC Program/Specialty PACT. The Clinical Social Worker coordinates a variety of activities including outreach, interdisciplinary activities, psychosocial assessments, treatment planning, consultation/education to Medical Center staff and community based service providers, the collection and maintenance of statistical data, program planning evaluation and modification, and the supervision of students as assigned. Screening/Assessment - The Social Worker will develop an assessment of the Veteran in collaboration with the interdisciplinary treatment team, the Veteran, and family members/significant others, whenever possible. The goal of the assessment is to highlight the Veteran's strengths, limitations, and internal/external supports and service needs in order to optimize the Veteran's functional status and safely maintain the Veteran in his/her home. Within the HBPC Program the assessment will include a home visit. The initial assessment and assessment updates will be completed as specified by the policy for the assigned work area. Treatment Planning/Goal Setting - The Social Worker is responsible for contributing to the development of the treatment plan and setting achievable treatment goals with the Veteran, family members/significant others and other HBPC/Specialty PACT clinical staff. Referral to service providers - Throughout the course of treatment, the Social Worker is the subject matter expert on VA and/or community resources. The Social Worker will collaborate with other service providers in reassessing the Veteran's needs for non-institutional, institutional services/programs and entitlements. The Social Worker is responsible for educating the Veteran and families/significant others of the available services and assisting them in establishing the appropriate referrals based on the Veteran's preference or that of his surrogate decision-maker. Resource Development - The Social Worker is responsible for developing a resource file of VA and community social service programs and enhancing the content to the benefit of Veterans. The Social Worker will refer the Veteran to needed services. Advocacy - The Social worker understands the intimidation of bureaucracy and will act as an advocate when it serves the best interest of the Veteran and family members/significant others. When appropriate and feasible, Social Worker will educate and encourage the Veteran to advocate on his/her own behalf, thus fostering a sense of independence and empowerment. Crisis Intervention - The Social Worker is experienced in making rapid assessments and developing crisis management plans. The Social Worker has access to multiple resource directories in addition to previously developed resources to meet the demands of a crisis. In the event of a medical or psychiatric emergency, the Social Worker will follow the protocol of HBPC Program and Ann Arbor VA Medical Center. Education/Health promotion and prevention - The Social Worker provides education related to VA and community resources, entitlements, Advance Directives/Living Will and will refer Veterans and families/significant others to the appropriate interdisciplinary team member for identified health education needs. Coordination of non-institutional and institutional services - The Social Worker is responsible for the coordination of the 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. The Social Worker is also responsible for the coordination of the referrals of institutional placements in Adult Foster Homes, Medical Foster Homes, Assisted Living Programs, CNH, or VA CLC. This includes reviewing the progress notes from the other providers to accurately determine the strengths and limitations of each Veteran being referred for non-institutional and institutional alternatives. The Social Worker will educate the Veteran, their family members/significant others and the team of all the options available to them and will collaborate with the Veteran and family members/significant others on the preferred option. Supportive counseling - The Social Worker will provide the Veterans and their caregivers with ongoing supportive counseling. The purpose of such counseling is to deal with the psychosocial impact of coping with chronic/disabling illness (es), onset of a catastrophic illness and need for non-institutional or institutional services, as needed, during the course of the Veteran's enrollment in the HBPC Program/Specialty PACT. Work Schedule: Monday-Friday (8:00 a.m. to 4:30 p.m.) Financial Disclosure Report: Not required
Providing Health Care for Veterans: The Veterans Health Administration is America’s largest integrated health care system, providing care at 1,255 health care facilities, including 170 medical centers and 1,074 outpatient sites of care of varying complexity (VHA outpatient clinics), serving 9 million enrolled Veterans each year.