The Patient Aligned Care Team (PACT) 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.

Duties

Duties may include, but are not limited to: The incumbent must use a high level of skill in assessing and treating the complicated psychosocial problems of Veterans and their families/significant others. Social Work responsibilities include the assessment of psychosocial problems that cause distress, often impacting the health condition and creating barriers to care. These stressors can include adjustment to the current medical condition, untreated or under-treated mental health or substance abuse condition, economic instability, legal problems, and inadequate housing and transportation. Referrals typically originate from any member of the interdisciplinary team, from Veterans and/or their families who call or walk-in for assistance, and from community professionals. The incumbent must complete thorough assessments to determine the underlying causes of the presenting problem, the interpersonal and environmental factors impacting the problem, and its affect on the patient's ability and desire to comply with the treatment recommendations by the multidisciplinary team. The social worker will help the patient and family to understand the contributing factors to the problem(s), will discuss with them the pros and cons of possible short-term and long-term solutions, encouraging them to make positive and lasting changes to reduce stressors. The social worker will coordinate with VA staff and community agencies to assist in problem solving as needed. Case management with members of the outpatient interdisciplinary team is provided in order to coordinate a collaborative effort to meet the agreed upon goals for a Veteran's treatment needs and include liaison with community professionals regarding needed services for Veterans and/or their families. The incumbent may complete Caregiver Support Program home visits for veterans assigned to their PACT team. The incumbent may provide Emergency Department coverage on a rotating basis. The incumbent must have a high level of skill and expertise to establish and maintain effective therapeutic relationships with Veterans in the Primary Care Clinic and/or their families. The incumbent is able to independently work with Veterans and their families who are experiencing a wide range of complicated medical, psychiatric, emotional, behavioral, financial, legal and psychosocial problems. Effective social work in the Patient Centered Medical Home context often occurs over a series of several visits and may involve the need of the social worker to visit the veteran in their home. Must independently complete thorough psychosocial assessments to determine the psychosocial functioning and needs of Veterans and/or their families. Must actively participate as a member of the interdisciplinary treatment team and actively participate through collaboration with Veterans and family as well as interdisciplinary treatment team members in the development and implementation of treatment goals and interventions. Must possess a working knowledge and experience in use of medical and mental health diagnoses, disabilities, and treatment procedures, including acute, chronic and traumatic illnesses, substance abuse disorders, common medications and their effects/side effects, and medical terminology. Must facilitate action for community placements through collaboration with Veterans and their families as well as interdisciplinary treatment team members to ensure that appropriate community placements are completed in a timely manner. Community placements can involve but are not limited to referrals to group and family care homes, assisted living facilities, adult day health care programs, contract nursing homes, Community Living Centers, residential care homes, inpatient and outpatient hospice services. Must serve as a liaison between Veterans and/or their families and VA and community resources in order to ensure thorough delivery of services. Must possess knowledge and ability to independently implement treatment modalities, provide educational classes, and/or supportive groups for Veterans and families, including shared medical appointments. The social worker must be able to use and teach Veterans in the effective use of the My HealtheVet (MHV) system. Must possess skill in using computer systems, especially the internet for Veterans who choose this modality to communicate with the team. Must provide consultation and education to Veterans and their families regarding community resources, VA benefits and specialty programs, and advance directives. Other duties as assigned. Work Schedule: Monday - Friday, 8:00 am - 4:30 pm (MST). Telework: Adhoc telework may be available at the supervisor's discretion and needs of the service. Virtual: This is not a virtual position. Functional Statement #: 554-58125-O/554-58126-O Relocation/Recruitment Incentives: May be Authorized Financial Disclosure Report: Not required

Requirements

Qualifications

Applicants pending the completion of educational or certification/licensure requirements may be referred and tentatively selected but may not be hired until all requirements are met. Basic Requirements: United States Citizenship: Non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy. Education. Have a master's degree in social work from a school of social work fully accredited by the Council on Social Work Education (CSWE). Graduates of schools of social work that are in candidacy status do not meet this requirement until the School of Social Work is fully accredited. A doctoral degree in social work may not be substituted for the master's degree in social work. Verification of the degree can be made by going to http://www.cswe.org/Accreditation to verify that the social work degree meets the accreditation standards for a masters of social work. Licensure. Persons hired or reassigned to social worker positions in the GS-0185 series in VHA must be licensed or certified by a state to independently practice social work at the master's degree level. Grade Determinations: Social Worker, GS-9 Experience, Education, and Licensure. None beyond the basic requirements. Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, the candidate must demonstrate all of the following KSAs: Ability to work with Veterans and family members from various socioeconomic, cultural, ethnic, educational, and other diversified backgrounds utilizing counseling skills. Ability to assess the psychosocial functioning and needs of Veterans and their family members, and to formulate and implement a treatment plan, identifying the Veterans problems, strengths, weaknesses, coping skills, and assistance needed. Ability to implement treatment modalities in working with individuals, families, and groups to achieve treatment goals. This requires judgment and skill in utilizing supportive, problem solving, or crisis intervention techniques. Ability to establish and maintain effective working relationships and communicate with clients, staff, and representatives of community agencies. Fundamental knowledge of medical and mental health diagnoses, disabilities, and treatment procedures. This includes acute, chronic, and traumatic illnesses/injuries; common medications and their effects/side effects; and medical terminology. Social Worker, GS-11 Experience and Licensure. Appointment to the GS-11 grade level requires completion of a minimum of one year of post-MSW experience equivalent to the GS-9 grade level in the field of health care or other social work-related settings, (VA or non- VA experience) and licensure or certification in a state at the independent practice level. Education. In addition to meeting basic requirements, a doctoral degree in social work from a school of social work may be substituted for the required one year of professional social work experience in a clinical setting. Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, candidates must demonstrate all of the following KSAs: Knowledge of community resources, how to make appropriate referrals to community and other governmental agencies for services, and ability to coordinate services. Skill in independently conducting psychosocial assessments and treatment interventions to a wide variety of individuals from various socio-economic, cultural, ethnic, educational and other diversified backgrounds. Knowledge of medical and mental health diagnoses, disabilities and treatment procedures (i.e. acute, chronic and traumatic illnesses/injuries, common medications and their effects/side effects, and medical terminology) to formulate a treatment plan. Skill in independently implementing different treatment modalities in working with individuals, families, and groups who are experiencing a variety of psychiatric, medical, and social problems to achieve treatment goals. Ability to provide consultation services to new social workers, social work graduate students, and other staff about the psychosocial needs of patients and the impact of psychosocial problems on health care and compliance with treatment. Preferred Experience: Rural case management Primary care Hospital/Medical social work References: VA Handbook 5005/120, Part II, Appendix G39 The full performance level of this vacancy is 11. The actual grade at which an applicant may be selected for this vacancy is in the range of 9 to 11. Physical Requirements: Must be in overall good health, able to sit at a desk working at a computer, engage in light to moderate physical activity including sitting, walking, bending, and carrying supplies. Social Worker must be able to perform primarily light and sedentary duties with occasionally moderate physical demands, exercise patience, and control emotions, with reasonable accommodation if necessary, without endangering the health and safety of the social worker or others. Position requires walking throughout the clinic and/or Medical Center, standing for extended periods of time, and involves sitting at a computer and in counsel and consultation with Veterans and interdisciplinary teams. Position will require travel into the community to meet with Veterans, Caregivers, community agencies, and partners who assist and support to the Caregiver Support Program and its Veterans. This position also requires close visual acuity to perform an activity such as: preparing and analyzing data and figures; transcribing; viewing a computer terminal; extensive reading; and repetitive motions of the wrists, hands, and/or fingers.

Education

IMPORTANT: A transcript must be submitted with your application if you are basing all or part of your qualifications on education.

Note: Only education or degrees recognized by the U.S. Department of Education from accredited colleges, universities, schools, or institutions may be used to qualify for Federal employment. You can verify your education here: http://ope.ed.gov/accreditation/. If you are using foreign education to meet qualification requirements, you must send a Certificate of Foreign Equivalency with your transcript in order to receive credit for that education. For further information, visit: http://www.ed.gov/about/offices/list/ous/international/usnei/us/edlite-visitus-forrecog.html.

Contacts

• Address Eastern Colorado HCS Denver 13611 E. Colfax Ave Aurora, CO 80045 US
• Name: Sokhan York
• Phone: 801-584-1284 X3119
• Email: [email protected]