The Transitions of Care (TOC) Coordinator assigned to the Durham VA Health Care System (DVAHCS) and is administratively responsible for the Transitions of Care program. The coordinator oversees daily operations of TOC programs, develops policies and procedures for program operation, and prepares reports, statistics and presentations for facility, VISN and national use. The coordinator collaborates closely with a Registered Nurse who also implements these programs throughout the system.

Duties

VA Careers - Social Work: https://youtube.com/embed/enRhz_ua_UU The TOC coordinator independently provides clinical psychosocial and case management services at an advanced practice level to eligible Veterans and their family members to meet biological, psychological, social, and environmental needs during the high-risk period of transition between different levels of care. The health care and psychosocial problems and needs of this population are complex and require a high degree of clinical oversight and creative problem solving. The incumbent is required to interact not only with the patient but also family, significant others, community agencies, and other staff. The TOC social worker System (HCS): 1) Transitions between crisis/acute care services (PEC/ED, PARC) to outpatient or residential care; 2) Inter-hospital transitions (PEC to PARC, C/L to PARC, PACT to PEC); 3) Outside facilities (VA and Community) to the Durham VA HCS (ED to ED, Inpatient to Inpatient, Inpatient to Durham VA HCS Outpatient: 4) Between programs (PEC to Access, PCMHI to Access, Access to home clinic). The TOC team aims to demonstrate improved transitional care coordination via designated VA metrics, such as the PDE1 MH SAIL measure. The TOC Coordinator is also responsible for promoting transitions from specialty MH care to Primary Care through Implementation of the VHA FLOW Initiative. The coordinator utilizes the National FLOW Dashboard to identify Veterans who meet key criteria which indicates potential readiness for transition from specialty mental health care to a general primary care setting in order to meet ongoing mental health care needs. Implementation of FLOW is intended to support both appropriate clinical decisions making and to improve access in critical areas of specialty mental health care (Primarily pharmacotherapy provided by MDs and Advance Practice Practitioners). The FLOW Coordinator uses the available Dashboard to continually identify patients in advance of upcoming appointments who may benefit from transition to primary care and communicate with BHIP and other mental health team providers to ensure that clinical review and decision-making occur. The coordinator is responsible for offering consultation and support to providers including Primary Care Mental Health Integration (PCMHI) and Primary Care stakeholders. The TOC will promote the use of transition procedures and educate staff on best practices for supporting Veterans and Primary Care staff through the transitions of patients out of MH specialty care. The TOC Coordinator also serves as an immediate resource to any stakeholders requiring clinical support to Veterans in transition, or to return Veteran back to specialty MH care after a trial when necessary. FUNCTIONS OR SCOPE OF ASSIGNED DUTIES The coordinator utilizes the National Post-Discharge Engagement (PDE) and FLOW Dashboards that compile electronic medical record data to identify Veterans in need of clinical contacts that will facilitate appropriate clinical services during important care transitions. - The coordinator manages aspects of transition that are not currently covered by other teams within the DVAHCS continuum of care. These aspects include follow-up face-to-face appointments, phone contacts, and case management to ensure transition plans are executed as intended. TOC Coordinator addresses case management needs them and/or bridges the gaps between psychotherapy services briefly. - Services provided may include individual and group aftercare psychotherapy. - The coordinator develops and maintains systematic approaches to engage Veterans' outpatient providers to ensure Veteran contact and engagement with the long-term care team as quickly as possible following a discharge/transition. - This coordinator uses knowledge of the VA and community mental health and healthcare systems, but also knowledge of recovery-based principles, advocacy skills, and evidence-based psychotherapy to optimize treatment plans. - The coordinator tracks engagement with identified Veterans via the PDE dashboard on a daily basis and follows up on all Veterans in need of contacts that have not already been completed in a timely fashion. - The coordinator identifies systemic and procedural barriers to timely and appropriate patient access to care. The coordinator will work with Outpatient Division and Outpatient Clinic Directors, as well as Acute Care Division and Clinic Directors to address inefficient and ineffective processes or service gaps. - The coordinator liaises with clinical providers at outside community facilities and at other VA facilities to provide appropriate outpatient appointments within 7 days of discharge and to assist in finalizing transitions plans that align with the VA MH Continuum of Care. - The coordinator attends monthly National Work Schedule: 0800-1630, M-F Telework: Ad-Hoc 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: 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). 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 Master 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/. Failure to Obtain License or Certification. In all cases, social workers must actively pursue meeting state prerequisites for licensure or certification starting from the date of their appointment. Failure to become licensed or certified within the prescribed amount of time will result in removal from the GS-0185 social worker series and may result in termination of employment. Loss of Licensure or Certification. Once licensed or certified, social workers must maintain a full, valid, and unrestricted independent license or certification to remain qualified for employment. Loss of licensure or certification will result in removal from the GS-0185 social worker series and may result in termination of employment. 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). GRADE DETERMINATIONS. In addition to the basic requirements for employment, the following criteria must be met when determining the grade of candidates. Social Worker (Program Coordinator), GS-12 (1) Experience and Education. One year of experience equivalent to the GS-11 grade level. Experience must demonstrate possession of advanced practice skills and judgment, demonstrating progressively more professional competency. Candidate may have certification or other post-master's degree training from a nationally recognized professional organization or university that includes a defined curriculum/course of study and internship, or equivalent supervised professional experience. (2) Licensure/Certification. Individuals assigned as social worker program coordinator must be licensed or certified at the advanced practice level and must be able to provide supervision for licensure. [(3) Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, the candidate must demonstrate all of the following KSAs: (a) Knowledge of program coordination and administration which includes consultation, negotiation, and monitoring. (b) Knowledge and ability to write policies, procedures, and/or practice guidelines for the program. (c) Ability to supervise multidisciplinary staff assigned to the program. (d) Skill in organizing work, setting priorities, meeting multiple deadlines, and evaluating assigned program area(s). (e) Ability to provide training, orientation, and guidance within clinical practice. (4) Assignments. For all assignments above the full performance level, the higher-level duties must consist of significant scope, complexity (difficulty), and variety and be performed by the incumbent at least 25% of the time. Program coordinators at the GS-12 grade level are administratively responsible for a clinical program providing treatment to Veterans in a major specialty area, such as but not limited to: Spinal Cord Injury, Homeless Continuum Veteran Program, Hospice and Palliative Care Program, Suicide Prevention Program, Veterans Justice Outreach, Caregiver Support Program and Community Nursing Home Program. The program coordinator may be the sole practitioner in this specialty at the facility and typically provide direct patient care services in the program area. The program coordinator oversees the daily operation of the program, develop policies and procedures for program operation, and prepare reports and statistics for facility, VISN, and national use. They may be responsible for the program's budget, developing and monitoring staff compliance with practice, standards and guidelines on documentation, workload, data entry, ethical practice and service delivery. The program coordinator provides analysis and evaluation of clinical program data and computerized programs to identify system-wide trends and needs to enhance the quality of service. They may be responsible for, or contribute to, the program's resource and fiscal management, monitoring control points developing the annual budget, operating within that budget, and accounting for appropriated funds. The program coordinator is administratively responsible for the clinical programming and prepares reports and statistics for facility, VISN, and national use. They provide leadership, direction, orientation, coaching, in-service training, staff development, and continuing education programs for assigned staff. They initiate and conduct a variety of program or service audits and complete designated clinical practice audits and reports, including productivity assessments. They oversee program operations and evaluations, identifying areas for improvement, gathering relevant data, assessing the data, developing and implementing ideas for improvement and evaluating efficacy of improvement efforts.] References: VA HANDBOOK 5005/120 September 10, 2019 PART II APPENDIX G39 The full performance level of this vacancy is GS-12. The actual grade at which an applicant may be selected for this vacancy is GS-12

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

Contacts

• Address Durham VA Medical Center 508 Fulton Street Durham, NC 27705 US
• Name: Gary Byles
• Phone: 919-824-1988
• Email: [email protected]