The Patient Aligned Care Team (PACT) is a comprehensive, multidisciplinary team which delivers patient-centered primary care. 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.

Duties

VA Careers - Social Work: https://youtube.com/embed/enRhz_ua_UU Major duties include, but not limited to: Incumbent is a professional social worker assigned to practice alongside the Veteran's Patient Aligned Care Team (PACT) and within the CC&ICM concept. 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 collaborates with nursing care managers and other members of the interdisciplinary team as needed for Veterans with needs at varying complexities through psychosocial assessments, quality case management, clinical treatment, achievable treatment goals, advocacy, and linkage with appropriate VA and community resources as needed by the Veteran. 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. Coordination and provision of the following services may include as appropriate activities of daily living; Advanced Directives and Goals of Care conversations; home health services; prosthetics; medical supplies; vocational rehabilitation; peer counseling; transportation and finances; home evaluations; housing alternatives; nursing homes and respite care; and development and utilization of community resources. The incumbent may provide individual, family, and group counseling aimed at assisting Veterans and family members to find practical solutions to complex problems. The incumbent: A. Must have a high level of skill and expertise to establish and maintain effective therapeutic relationships with Veterans and their personal support system. B. 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. C. The incumbent must be able to utilize this assessment in facilitating the Veteran's maximum use of treatment for attainment of the highest level of independence that is possible and practicable. D. Establishes collaborative relationships with physicians, nurses, and other disciplines to foster their involvement in care of Veterans with complex care coordination needs. E. Incumbent 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. F. Must actively participate as a member of the interdisciplinary treatment 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. G. 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. H. Must have an understanding of caregiver stressors, ability to conduct caregiver assessment and provide appropriate caregiver specific interventions. I. Incumbent must possess skills and knowledge to provide case management services to Veterans identified as complex risk on the care continuum. J. Must possess knowledge and ability to independently implement treatment modalities and evidence-based practices as well as provide educational classes, and/or supportive groups for Veterans. K. Must provide consultation and education to Veterans and their personal support system regarding community resources, VA benefits and specialty programs, and Advance Directives. Work Schedule: Monday - Friday; 8:00am - 4:30pm Telework: Available Virtual: This is not a virtual position. Functional Statement #: Social Worker - Patient Aligned Care Team (PACT) Care Coordination / PD000000 Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): 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. 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. Current state requirements may be found by going to http://vaww.va.gov/OHRM/T38Hybrid/. 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. Physical Requirements. See VA Directive and Handbook 5019, Employee Occupational Health Services. 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: 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. OR 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: 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 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-09 to GS-11. Physical Requirements: The work is sedentary. Some work may require movement between offices, hospitals, warehouses, and similar areas for meetings and to conduct work. Work may also require walking/standing, in conjunctions with travel to and attendance at meetings and/or conferences away from the work site. Incumbent may carry and lift light items weighing less than 15 pounds.

Education

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: https://sites.ed.gov/international/recognition-of-foreign-qualifications/.

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]