This position is eligible for the Education Debt Reduction Program (EDRP), a student loan payment reimbursement program. You must meet specific individual eligibility requirements in accordance with VHA policy and submit your EDRP application within four months of appointment. Approval, award amount (up to $200,000) and eligibility period (one to five years) are determined by the VHA Education Loan Repayment Services program office after complete review of the EDRP application.
Duties
Social Worker is based within the Behavioral Health Interdisciplinary Program (BHIP) at the Roseburg VA Healthcare System. The incumbent in this position independently provides an array of case management, longitudinal care coordination, and clinical psychotherapy/recovery services.The incumbent may maintain a small caseload (up to 20% of a full-time therapist) of psychotherapy clients but functions primarily as a case manager.Case management includes systems collaboration and the linking of Veterans with complex needs, their families, and caregivers with needed services and resources, including wellness opportunities. Case management may include basic, moderate, or complex levels of care coordination, and fall along the continuum from intensive, to stabilization, into maintenance, and then supportive services.
FUNCTIONS OR SCOPE OF ASSIGNED DUTIES
1. Comprehensive Case Management Assessment and Reassessments. The CM completes a comprehensive assessment of the concerns, needs, and preferences of the Veteran and their family or caregiver. The assessment includes elements such as military history, social supports, housing, transportation, education and employment, income and finances, and initial care plan. Subsequent reassessments/monitoring are created in collaboration with the Veteran, their family or caregiver, and interprofessional team, as clinically indicated. Assessments are documented in the EHR.
2. Goal(s) and Resource Identification. The CM identifies and prioritizes the Veteran's and their family/caregiver's desired or expected goal(s) and outcome(s), as well as a resource assessment to identify available benefits, assistive options, and appropriate services and resources within and outside VHA. Resources may include existing natural supports, and internal skills and coping mechanisms.
3. Care Planning, Implementation, and Communication. The CM plans and implements a care plan through coordination and collaboration with the Veteran, the family or caregivers, and VHA and community providers. The intensity and duration of CM services are dependent on the Veteran's care needs. The CM assists Veterans/caregivers with system navigation, and linking them in a timely manner to health, mental health, health education, self-management and social services, community-based resources, or benefits, as clinically indicated. The CM will facilitate proactive, patient-centric communication and information sharing between the Veteran or Servicemember, their family or caregiver, providers, and other care team members.
4. Therapeutic Engagement and Psychosocial Intervention. The CM will engage, develop, and maintain therapeutic relationships with both the Veteran, families, and caregivers, utilizing resiliency-based, recovery-oriented, Veteran-centered communication and practice techniques (e.g., Health Education, Health Coaching, Shared Decision Making, Motivational Interviewing, Solution Focused Work, Psychosocial Problem Solving, Strength-Based work) as well as time-limited psychotherapy to facilitate progress, growth, and positive lifestyle changes. If providing psychotherapy services, the CM conducts psychosocial screening and evaluations for the wide range of mental conditions utilizing best practices for initial and follow-up assessment (i.e., measurement-based care), as well as participates in the development of appropriate treatment plans. The CM provides emergency/crisis intervention services to outpatients experiencing acute psychological crises, helping to stabilize these individuals, assisting in the referral arrangements for transfer to a psychiatric facility for inpatient care if necessary and providing follow up care as needed.
5. Care Collaboration, Coordination, Referrals, and Transitions. The CM coordinates effective and timely referrals to ensure the appropriate level and type of care, working collaboratively with VA teams based in Roseburg (e.g., PACT, Home Based Primary Care, primary-care mental health integration, Whole Health, specialty substance abuse and PTSD, Suicide Prevention Coordinators, Local Recovery Coordinator, Veterans Justice Outreach, Housing and Urban Development Department of Veterans Affairs Supportive Housing; Health Care for Homeless Veterans; Grant and Per Diem, Transition and Care Management, Caregiver Support Program, APU, and MHRRTP), and other resources across VISN 20. The CM manages transitions of the Veteran to other VHA, DoD, other Federal, State, and local home and community-based services (to include the Office of Community Care).
Work Schedule: Monday - Friday, 8:00-4:30 pm
Telework: Available upon Supervisor approval.
Virtual: This is not a virtual position.
Relocation/Recruitment Incentives: Authorized
EDRP Authorized: Contact
[email protected], the EDRP Team for questions/assistance. Learn more
Permanent Change of Station (PCS): Not Authorized
Financial Disclosure Report: Not required