The social worker will provide veterans in the Home Based Primary Care (HBPC) with high quality case management, clinical assessment/treatment, advocacy, and coordinate linkage with appropriate VA community service providers/ agencies as needed by the client. This is accomplished in collaboration with other members of the HBPC Team and/or other interdisciplinary treatment teams as appropriate, ie, outpatient providers, social work and other treating specialist. This job requires 75% travel time.

Duties

Screening/Assessment - The social worker will develop an assessment of the veteran in collaboration with the interdisciplinary treatment team, the veteran, family members and significant others upon receipt of initial referral. The social worker will address the initial referral in a timely manner in accordance with SW/ HBPC policy with completion of the psychosocial assessment. The goal of the assessment is to highlight the veteran's strengths, limitations, and internal/external supports and service needs, (specific to the injury and current medical status) to ensure and optimize the veteran's functional status, living environment and to safely maintain the veteran in his/her home. The assessment will include home visits and will be scheduled according to the SW/HBPC policy. All services provided will be in collaboration with other disciplines including providers nursing and support staff. Annual assessments will be completed according to policy as well. Treatment Planning/Goal Setting - The social worker is responsible for developing the treatment plans and setting achievable treatment goals with the veteran/family in collaboration with the HBPC interdisciplinary treatment team members. The social worker will continue to monitor the veteran at home and complete ongoing assessments/process notes according to specifics of the treatment plan. The treatment plan will reflect timely updates of the patient status and change in plan of care. The number of home visits will be determined patient need/concerns. The social worker will work collaboratively with the veteran's assigned Firm/clinic social worker as appropriate for discharge planning, and community services. The treatment plan will be completed and updated as needed to reflect specifies related to change in the patient's condition/plans. The social worker will attend and actively participate HBPC interdisciplinary care planning meetings, SW staff meetings and other meetings as appropriate to the clinical social work role. The social worker will complete annual evaluation on each patient and document assessment in a timely manner. Referrals to service providers - Throughout the course of treatment the social worker is the subject matter expert of VA and community resources. The social worker will collaborate with other service providers in reassessing the veteran's needs for non-institutional, institutional services/programs and entitlements. The social worker is 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 decisionmaker Resource Usage/Development - The social worker is responsible for developing a resource file of VA and community service programs and will refer the veteran to needed services. The social worker will maintain resource directories sufficient to meet a variety of situations and conditions across age and gender specific needs. Advocacy - Social worker understands the intimidation of bureaucracy and will act as an advocate when it serves the best interest of the veteran/family. When appropriate and feasible, social worker will educate and encourage the veteran/family to advocate for themselves, thus fostering a sense of independence and empowerment. Crisis Intervention - Social worker is experienced in making rapid assessments and developing crisis management plans for referral to appropriate MH services. Social worker has access to multiple resource directories in addition to previously developed resources to meet the demands of a crisis. In the event of a medical or psychiatric emergency, staff will follow the protocol of the HBPC Program. Social worker is experienced in making rapid assessments and developing crisis management plans to maintain patient in the home, for admission to acute, short term and/or long-term placements. Supportive counseling - Social worker will provide the veterans and their caregivers with ongoing supportive counseling. The purpose of such counseling is to dealt with the psychosocial impact of coping with chronic/disabling illness (es), onset of catastrophic illness and/or dying, need for non-institutional or institutional services as needed during the course of the veteran's enrollment in the HBPC Program. Education/Health Promotion and Prevention - Social worker provides education related to VA and community resources, entitlements, Advance Directives/Living Will and will refer veterans/families to the appropriate interdisciplinary team member for identified health education needs. Work Schedule: Monday thru Friday 8:00 am to 4:30 pm Telework: Not Available Virtual: This is not a virtual position. Functional Statement #: 92154 Relocation/Recruitment Incentives: Not Authorized Financial Disclosure Report: Not required

Requirements

Qualifications

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. Licensure. Persons hired or reassigned to social worker positions in the GS-185 series in VHA must be licensed or certified by a state to independently practice social work at the master's degree level. English Language Proficiency. Social workers must be proficient in spoken and written English in accordance with VA Regulations. Grade Determinations (GS-11, Full Performance Level) Experience, Education and Licensure. GS-11 full performance level requires completion of a minimum of I year of post-MSW degree experience in the field of health care social work (VA or non-VA experience) and licensure or certification in a state at the independent practice level. OR, In addition to meeting basic requirements, a doctoral degree in social work from a school of social work may be substituted for the required 1 year of professional social work experience in a clinical setting. Assignments. This is the full performance level for social workers. GS-11 social workers are licensed or certified to independently practice social work. They are assigned to all program areas, including inpatient or outpatient medicine, surgery, mental health, neurology, rehabilitation medicine, and geriatrics. Employees provide professional, independent social work services in the assigned area. References: VA Handbook, Part II, Appendix G39 The full performance level of this vacancy is GS-11.The actual grade at which an applicant may be selected for this vacancy is in the GS11. Preferred Experience: Case Management Physical Requirements: The social work duties include sedentary and ambulation (walking) throughout the medical center and in the community according to the demands of daily tasks. Light carrying, less than 15 pounds-may be required as part of duties related to storing or moving files. Working around moving objects or vehicles-required as part of daily ambulating within the medical center around patients who use motorized scooters and wheelchairs. Working along-duties require working along at intervals during the day (i.e., documenting progress notes, completing phone call, etc.). Reaching above shoulder- may be required during daily task to access files located in overhead cabinets. Walking- required approximately 3-4 hours daily associated with walking from assigned office to outpatient clinics and other medical center departments as needed to complete duties of the position. Standing-required approximately 3-4 hours daily associated with walking from assigned office to outpatient clinics and other departments within the medical center as needed to complete duties of the position and filling patient records as needed. It is required that this individual be able to operate a motor vehicle as this position and it is expected that the incumbent visit patients off-site as part of their duties. Work will take place in- and outdoors thus exposing them to the natural elements of the weather.

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 John D Dingell Department of Veterans Affairs Medical Center 4646 John R Street Detroit, MI 48201 US
• Name: Janice Uselton
• Phone: 313 942 5488
• Email: [email protected]