The Post-9/11 M2VA Social Work Case Manager provides comprehensive social work case management service to Post-9/11 transitioning and established Servicemembers and Veterans (SM/Vs) and their families across the continuum of care and during the various phases of readjustment to civilian life. The incumbent independently provides an array of social work interventions including high-risk screening, psychosocial assessments, treatment planning, resource education and referral, and case management. ***THIS IS AN OPEN CONTINUOUS ANNOUNCEMENT*** This vacancy will remain open until filled. The first cut-off date is 07/29/2021. Additional applications will be referred as needed. The primary responsibility of the position is to coordinate care and services for ill and injured transitioning Servicemembers and Veterans and others in need of case management services. Contacting active duty Servicemembers and Veterans prior to transfer for inpatient admission and initial outpatient appointments to answer any questions about upcoming appointments. Assisting to resolve any issues at the local level to include ensuring appointments are scheduled, authorizations are obtained, family resources are secured, and any psychosocial issues are addressed (temporary lodging, home modifications, community resources, in-home services, etc.). Completing and documenting a comprehensive case management assessment, updating the assessment as necessary based on clinical judgment, and developing a case management plan of care. Documentation will: a) Include information about significant interactions with the patients (whether by telephone or in person). b) Occur in the Computerized Patient Record System (CPRS) utilizing appropriate stop codes. c) Occur in the Care Management Tracking and Reporting Application (CMTRA) and/or the Interagency Comprehensive Plan (ICP) in the Federal Case Management Tool (FCMT), an electronic database that provides the Post-9/11 M2VA Case Management team with a means to identify and track ill or injured Servicemembers and Veterans receiving case management services. Continually assessing the need for a change in case management services and adjusting the level of intervention as appropriate based on the medical and psychosocial needs of the Veteran and family. Supporting and educating the patient and family, referring Veterans to VA program and services, referring Veterans to home and community based services, visiting Veterans in their homes if appropriate, and crisis intervention. Working closely with the Post-9/11 M2VA Case Management Program Manager to ensure all needs are met. Educating the patient and family to understand who the primary POC/Lead Coordinator is for questions and concerns and providing contact information. Coordinating any necessary care and services at the VA medical facility that the active duty Servicemember will use while on convalescent leave. The Post-9/11 M2VA Social Work Case Manager at that VA medical facility will make contact with the Servicemember as an introduction. If the convalescent leave is planned for 30 days or less and the Servicemember does not plan to use local VA services during that time, the Post-9/11 M2VA Social Work case manager will continue to be available to address issues or concerns. If the convalescent leave needs to be extended, the Post-9/11 M2VA Social Work case manager will contact the DoD case manager and VA Liaison to obtain necessary authorizations for continued care. Supporting Veterans and their families during transition. Transitions include, but are not limited to: a) Transfer from the MTF to a VA medical facility, skilled nursing facility admission, and transfer of care to a new VA medical facility. b) Change in patient's psychosocial status (e.g. caregiver stress, divorce, decline in support system, death of a family member, loss of job, new employment, substance abuse, etc.). c) Patient and family relocation. d) Significant change in medical status and functional decline. Serving as the Lead Coordinator when deemed appropriate by the CMT. If functioning as the LC, responsibilities include: a) Serving as the primary POC for Servicemembers and Veterans and their families or caregivers for coordination of care, benefits, and services related to the ICP. However, other members of the CMT may communicate with the Servicemember or Veteran. The LC will identify potential conflicts in the ICP and facilitate resolution within the CMT. b) Communicating with the Servicemember or Veteran and family or caregiver on an ongoing basis (in person, when possible), and will provide them with contact information for the LC and other members of the CMT. The contact information will be updated as changes occur. c) Updating the CMT during the regularly scheduled CMT meeting and ensuring the ICP is updated on a periodic basis to include at least the following milestones: at the time of transfer from one facility to another or to another geographic area; at the time of discharge from inpatient to outpatient status; upon transfer to an outside or private entity, or upon significant change in the Servicemember's or Veteran's condition. Work Schedule: Monday - Friday, 8 AM - 4:30 PM (Hours may vary based on need). 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.