The Social Worker is assigned to the Intensive Management Patient Aligned Care Team (IMPACT) serving San Francisco VA Health Care System primary care clinic and the Community Based Outpatient Clinics CBOCs. IMPACT serves as an adjunctive arm of each PACT. IMPACT works to extend PACT support into the community setting. The caseload consists entirely of complex and often high-risk patients, including high utilizers; persons with dementia with extreme lack of social support; Veterans with high CAN scores indicating the highest risk of hospitalization or death. The role of the Social Worker is to provide community based social work services to the Veteran and family/support system when indicated and to collaborate and communicate with the Veteran, support system, IMPACT and primary PACT teams
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