The Social Worker provides Veterans in the Charles George VA Medical Center Primary Care Team with high quality case management, clinical treatment, advocacy, and coordination with appropriate VA and community service providers I agencies as needed by the client. This is accomplished in collaboration with other members of the interdisciplinary treatment team as well as with appropriate clinics and programs, i.e. Specialty Clinics, CLC etc. Duties include but not limited to: Develops an assessment of the Veteran in collaboration with the interdisciplinary treatment team, the Veteran, family members and significant others, whenever possible. Responsible for developing the treatment plan and setting achievable treatment goals with the Veteran/family in collaboration with the interdisciplinary treatment team members. Attends weekly interdisciplinary care planning meetings; ongoing assessments and will update treatment plans when necessary or as health status changes. Address the unique needs of homebound, frail, disabling/chronic and/or dying Veterans. The social worker will collaborate with other service providers in reassessing the Veteran's needs for non-institutional, institutional services/programs and entitlements. Responsible for educating the Veteran and/or caregiver 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. Develops a resource file of VA and Community social service programs and will refer the Veteran to needed services. Acts as an advocate when it serves the best interest of the Veteran/family. Makes rapid assessments and developing crisis management plans to maintain patient in the home, for admission to acute, short term and/or long-term placements. Provides education related to VA and community resources, entitlements, advance Directives/Living Will and will refer Veterans /family to the appropriate interdisciplinary team member for identified health education needs. Coordinates all referrals of non-institutional services such as ADHC/CADHC, inpatient hospice, home hospice, skilled and non-skilled homecare services in collaboration with the interdisciplinary treatment team members. Work Schedule: Monday-Friday, 8:00am - 4:30pm Telework: Not Available Virtual: This is not a virtual position. Functional Statement #:000000 Relocation/Recruitment Incentives: 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.
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