Care Coordination Social Worker will focus on the concept of Care Coordination & Integrated Case Management (CC&ICM). CC&ICM is a specialized, collaborative practice among multiple interprofessional health care teams that emphasizes the importance of patient stratification by acuity, risk, and intensity into an appropriate level of care coordination. Will oversee care coordination and facilitate interprofessional team communication, reduce task and intervention duplication.

Duties

Duties include but are not limited to: Incumbent is a professional social worker assigned to practice within the CC&ICM concept that works alongside the Veteran's Patient Aligned Care Team (PACT). The incumbent must use a high level of skill in assessing and treating the complicated psychosocial problems of Veterans and their personal support system. Social work responsibilities include the assessment, treatment planning, and case management of psychosocial problems that cause distress, often impacting the health condition and creating barriers to care. These stressors can include but are not limited to: 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. The incumbent must complete thorough assessments to determine the underlying causes of the presenting problem(s), the interpersonal and environmental factors impacting the problem, and its effect on the Veteran's ability and desire to comply with the treatment recommendations by the multidisciplinary team. The social worker will help the Veteran and personal support team to understand the contributing factors to the problem(s), will discuss with them possible short-term and long-term solutions, and create a treatment plan with established goals to meet these needs. The social worker will coordinate with VA staff and community agencies to assist in problem solving as needed. Incumbent will serve as the Lead Coordinator for the Veteran and provide case management support. The incumbent: A. Must have a high level of skill and expertise to establish and maintain effective therapeutic relationships with Veterans and/or their personal support system. The incumbent is able to work with Veterans and their families who are experiencing a wide range of complicated medical, psychiatric, emotional, behavioral, financial, legal, and psychosocial problems. B. Establishes collaborative relationships with physicians, nurses, and other disciplines to foster their involvement in care of Veterans with complex care coordination needs. C. Must independently complete thorough psychosocial assessments to determine the psychosocial functioning and needs of Veterans and/or their personal support team. The incumbent is able to assess functional acuity of the Veteran and provide appropriate interventions. D. Must actively participate as a member of the interdisciplinary treatment team, Care Coordination Review Team, and actively participate through collaboration with Veterans and personal support system as well as interdisciplinary treatment team members in the development and implementation of treatment goals and interventions. E. 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. F. Identifies unmet needs of the Veterans identified with complex risk and works collaboratively with community agencies, i.e., assisted living facilities, nursing homes, handicapped accessible housing and state Veterans' homes. G. Incumbent must possess skills and knowledge to provide case management services to Veterans identified as complex risk on the care continuum. The incumbent will be able to appropriately utilize principles of human growth and development over the life span and will be able to assist Veterans in coping with the loss and experiences from disability and chronic illness. H. Must possess knowledge and ability to independently implement treatment modalities and evidence-based practices. 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. I. Must have knowledge of the signs and symptoms of abuse, neglect, and exploitation. J. Must possess and demonstrate ability to communicate effectively, both orally and in writing with people from varied backgrounds. K. Responsible for supporting the mission, policies, and procedures of the Department of Veterans Affairs, the Veterans Health Administration (VHA), the appropriate Veterans Integrated Service Network (VISN), and the facility. Work Schedule: Monday through Friday, 7:30 am - 4:00 pm or 8:00 am - 4:30 am Compressed/Flexible:Compressed Tour May Be Considered Telework: Telework May Be Considered Virtual: This is not a virtual position. Functional Statement #: Social Worker - Care Coordination/PD00000 Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized Financial Disclosure Report: Not Required

Requirements

Qualifications

Basic Requirements: The basic requirements for employment as a VHA social worker are prescribed by statute in 38 U.S.C. § 7402(b)(9), as amended by section 205 of Public Law 106-419, enacted November 1, 2000. To qualify for appointment as a social worker in VHA, all applicants must meet the following: a. Citizenship. Be a citizen of the United States. (Non-citizens may be appointed when it is not possible to recruit qualified citizens in accordance with chapter 3, section A, paragraph 3g this part). b. 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. c. 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. Current state requirements may be found by going to http://vaww.va.gov/OHRM/T38Hybrid/. d. Grandfathering Provision. The following is the standard grandfathering policy for all title 38 hybrid qualification standards. Please carefully review the qualification standard to determine the specific education and/or licensure/certification/registration requirements that apply to this occupation. e. Physical Requirements. See VA Directive and Handbook 5019, Employee Occupational Health Services. f. English Language Proficiency. Candidates must be proficient in spoken and written English to be appointed as authorized by 38 U.S.C. § 7403(f). May qualify based on being covered by the Grandfathering Provision as described in the VA Qualification Standard for this occupation (only applicable to current VHA employees who are in this occupation and meet the criteria). Grade Determinations: In addition to the basic requirements for employment, the following criteria must be met when determining the grade of candidates. Social Worker, GS-9 (1) Experience, Education, and Licensure. None beyond the basic requirements. (2) Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, the candidate must demonstrate all of the following KSAs: (a) Ability to work with Veterans and family members from various socioeconomic, cultural, ethnic, educational, and other diversified backgrounds utilizing counseling skills. (b) 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. (c) 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. (d) Ability to establish and maintain effective working relationships and communicate with clients, staff, and representatives of community agencies. (e) 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. (3) Entry Level Assignments. Individuals assigned as GS-9 grade level social workers are considered to be at the entry level and are closely supervised, as they are not yet functioning at the independent practice level conferred by independent licensure or certification. Social workers at the GS-9 entry level are typically assigned to program areas that do not require specialized knowledge or experience. Duties may include but are not limited to: identifying behaviors or symptoms of abuse, neglect or exploitation; providing education on advance directives and advanced care planning; providing social work case management; acting as an advocate with appropriate VA and community service providers/agencies when it serves the best interest of the Veteran and family members/caregiver; assessing the psychosocial functioning and needs of Veterans and their family members identifying the Veteran's strengths, weaknesses, coping skills and psychosocial acuity, in collaboration with the Veteran, family, and interdisciplinary treatment teams; maintaining a current network of internal and external resources to educate the Veteran and/or family members/caregivers and assist with the appropriate referrals. Since social workers at this level are not practicing at an independent level, they should not be assigned to program areas where independent practice is required, such as in a CBOC, unless there is a licensed social worker in the program area who can provide supervision for practice. GS-9 social workers provide psychosocial services in the assigned area under supervision. Social Worker, GS-11 (1) 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. NOTE: For appointment licensure or certification at this level please refer to paragraph 3c. OR (2) 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. GRADE DETERMINATION CONTINUED IN THE EDUCATION SECTION BELOW Preferred Experience: 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 personal support system. 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 interventions and delivery of care in the PACT setting often occurs over a series of several visits. Must have knowledge of the PACT team approach and the role of each health and allied health care team members as well as an understanding of the role of the social worker in the PACT model. Knowledge of community resources, how to make appropriate referrals to community and other governmental agencies for services, and ability to coordinate services. 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. References: VA Handbook 5005/120, Part II, Appendix G39, Social Worker Qualification Standard dated September 10, 2019. 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 range of GS-9 to GS-11. Physical Requirements: The work is primarily sedentary. It may require some lifting (10-20 lbs.) occasionally; Reaching above shoulder; Frequent keyboarding (4-7 hours per day); Sitting (4-7 hours per day); Walking (up to 6 hours per day); Standing (up to 8 hours per day); Infrequent climbing/descending of stairs; Some bending; Ability for rapid mental and muscular coordination simultaneously; Correctable near-sighted and far-sighted vision; Hearing (Aid permitted). Reference: See VA Directive and Handbook 5019, Employee Occupational Health Services.

Education

GRADE DETERMINATION CONTINUED:

(3) Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, candidates must demonstrate all of the following KSAs:
(a) Knowledge of community resources, how to make appropriate referrals to community and other governmental agencies for services, and ability to coordinate services.
(b) 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.
(c) 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.
(d) 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.
(e) 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.
(4) Full Performance Level Assignments. This is the full performance level. Social workers at this level are licensed or certified to independently practice social work. Incumbents are assigned to all program areas, including but not limited to: inpatient or outpatient medicine, surgery, mental health, neurology, rehabilitation medicine, and geriatrics. Employees provide professional, independent social work services in the assigned area. Duties include but are not limited to: assessing and documenting identified behaviors or symptoms of abuse, neglect, exploitation and/or intimate partner violence; use of clinical social work skills and knowledge to maintain Veteran privacy and confidentiality per policies, handbooks or directives; and acts as an advocate with appropriate VA and community service providers and agencies when it serves the best interest of the Veteran and family members/caregiver. Incumbent independently assesses the psychosocial functioning and needs of Veterans and their family members, identifying the Veteran's strengths, weaknesses, coping skills, and psychosocial acuity. In collaboration with the Veteran, family/caregiver, and interdisciplinary treatment team, the social worker facilitates the delivery of health care services. The social worker identifies family/caregiver stressors, conducts assessment and provides specific interventions. The incumbent provides case management and care coordination to facilitate appropriate delivery of health care services, incorporates complex multiple causation in differential diagnosis and treatment of Veterans, including making psychosocial and psychiatric diagnoses within approved clinical privileges or scope of practice. The social worker links the Veteran with services, resources, and opportunities, in order to maximize the Veteran's independence, health, and well-being. The social worker conducts timely assessment of at-risk Veterans in crisis to identify immediate needs, evaluate risk, and initiate safety plan as appropriate. The social worker provides interventions independently with Veterans and their families/caregivers who are experiencing a wide range of complicated medical, behavioral health, financial, legal, and psychosocial problems. They provide a range of interventions and treatment modalities which may include individual, group, and/or family counseling or psychotherapy. They independently formulate and implement a treatment plan including measurable, achievable goals identifying the Veterans' needs, strengths, weaknesses, coping skills, and psychosocial acuity. Social workers serve on committees, work groups, and task forces at the facility and VISN level or in the community. They provide subject matter consultation to colleagues and students on the psychosocial treatment of Veterans offering professional opinions based on experience, expertise and role modeling effective social work practice skills. The social worker establishes and maintains ongoing education programs for Veterans, community agencies, students, and staff, to facilitate understanding of social work interventions specific to the Veteran/Military population.

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

Accreditation Information: The master's degree in social work must be from a school of social work fully accredited by the Council on Social Work Education (CSWE). Verification of accreditation may be made obtained from CSWE.

Note: If your school has changed names, or is no longer in existence, you must provide this information in your application.

Note: If your school was accredited by the Council on Social Work Education (CSWE) at the time of graduation but is no longer listed on the CSWE website, you must provide documentation of accreditation with your application packet.

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 VA Central Texas Health Care System 1901 Veterans Memorial Drive Temple, TX 76504 US
• Name: VISN 17 SSU USAS Group
• Email: [email protected]