The Social Worker is assigned to the Rural Primary Aligned Care Team (RPACT). The Rural PACT SW will be supporting the needs of the highly rural Veteran population at the Hobbs, New Mexico, Community Based Outpatient Clinic (CBOC) and Ft Stockton VA Outreach Clinics. ***THIS IS AN OPEN CONTINUOUS ANNOUNCEMENT ***This vacancy will remain open until filled. The first cut-off date is 08/06/2021. Additional applications will be referred as needed. Screening/Assessment: The PACT Social Worker will complete an assessment of the Veteran in collaboration with the interdisciplinary treatment team, the Veteran, family members and significant others. The goal of the assessment is to identify needs and formulate a plan to meet those needs. Understands of the range of treatment and skills needed for all adult patients (including geriatric patients) related to their physical limitations, psychological needs and age associated illnesses and conditions. Treatment Planning/Goal Setting: Responsible for contributing to the development of the treatment plan and setting achievable treatment goals with the Veteran and family members/caregiver. Referral to service providers: The Social Worker is the subject matter expert on VA and/or community resources. The Social Worker collaborates with other service providers in reassessing the Veteran's needs. Responsible for educating the Veteran and family members/caregivers 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. Advocacy: The Social Worker understands the difficulty of bureaucracy and will act as an advocate when it serves the best interest of the Veteran and family members/caregiver. Educates and encourages the Veteran to advocate on his/her own behalf, thus fostering a sense of independence and empowerment. Acts as an advocate or authorized representative in accordance to SSI/SSDI Outreach, Access, and Recovery (SOAR) in accordance and completion of the training by Substance Abuse and mental Health Services Administration (SAMHSA). Crisis Intervention: The Social Worker is experienced in making rapid assessments and developing crisis management plans. Utilizes multiple resource directories in addition to previously developed resources to meet the demands of a crisis. Provides crisis intervention services, seeking to address the cause as well as the presenting complaint, coordinates family conferences and serves as liaison to family members. Maintains knowledge of Suicide Prevention policy and procedure, recognizes warning signs for suicide ideation or recent self-directed violence, and utilizes the identified screening tools to assess suicide risk. Education/Health promotion and prevention: Provides education related to VA and community resources, entitlements, Advance Directives/Living Will and will refer Veterans and family members/caregiver to the appropriate interdisciplinary team member for identified health education needs. Coordination of non-institutional and institutional services: Reviews the progress notes from the other providers to accurately determine the strengths and limitations of each Veteran. The Social Worker will educate the Veteran, their family members/caregiver and the team of all the options available to them and collaborates with the Veteran and family members/caregiver on the preferred option. Responsible for the monitoring of, and discharge planning for, Veterans assigned to the PACT Team while Veterans are hospitalized in any number of local medical facilities. Supportive counseling: The Social Worker provides the Veterans and their family members/caregiver with ongoing supportive counseling. This counseling deals with the psychosocial impact of coping with chronic/disabling illness(es), onset of a catastrophic illness mental illness(es), etc. Administrative responsibilities: The Social Worker will enter all Veteran/family contacts in the electronic record using appropriate formats and templates. This information will be reviewed with the patient on a regular basis. Establishes and maintains a positive working relationships with employees, volunteers, consumers and stakeholders within the VA and outside community agencies. Attends all appropriate staff meetings (interdisciplinary treatment team meetings, Social Work Service staff meetings, supervision meetings, and committees and workgroups, as appropriate) and perform other duties as required. The Social Worker collaborates in the performance improvement process and comply with performance measures as required by the VA for their specific population and/or program. Participates in "on call" coverage for Social Work Service. Performs other related duties as assigned. Work Schedule: Monday - Friday, 8:00 AM - 4:30 PM Telework: Not Available Virtual: This is not a virtual position. Functional Statement #: PD000000 Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized 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.