The Patient Aligned Care Team is a comprehensive team which delivers primary care to Veteran patients in a longitudinal rather than episodic fashion and which has as its focus; prevention; health promotion, coordination and chronic disease management. The social worker in this Veteran-centric approach often functions as a care coordinator with a panel of veterans to ensure that health care meets the needs, as defined by the Veteran, Responds promptly to patient referrals from the team/program to which assigned, as well as back-up rotations, maintaining contact at intervals appropriate to the needs of the particular case, and documents these contacts in the medical record periodically, as significant contacts occur. Provides direct clinical services to veterans
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