The incumbent provides Veterans in the Home-Based Primary Care (HBPC) Program with high quality case management, clinical treatment, advocacy, and to coordinate linkages with appropriate VA and community service providers/ agencies as needed by the client. This is accomplished in collaboration with other members of the HBPC Team or other interdisciplinary treatment teams as appropriate (i.e., Specialty clinics, Mental Health, etc).

Duties

This position requires regular travel throughout the James J. Peter VAMC catchment area Assessment and screening The incumbent performs assessments of the Veteran in collaboration with the interdisciplinary team, the Veteran, family members and significant others. The incumbent has skills to independently conduct psychosocial assessments and treatment interventions if needed. The goal of the assessment is to highlight the Veterans' strengths, limitations, and internal/external supports and service needs to optimize the Veteran's functional status and safely maintain the Veteran in his/her home. The assessment will include an initial home visit, an annual home visit and ongoing visits as clinically indicated. It is the responsibility of the social worker, working within the interdisciplinary treatment team to develop a treatment plan with the Veteran based on this assessment. Treatment Planning and Goal Setting The social worker responsible for developing the treatment plan and setting achievable treatment goals with the veteran/family in collaboration with the HBPC interdisciplinary treatment team members. They will include psychosocial problems in the interdisciplinary treatment plan and educate staff on the impact of psychosocial problems on healthcare and compliance with treatment. Will attend regular interdisciplinary care planning meetings as scheduled. Ongoing assessments and updating treatment plans are done when necessary or on an annual basis given the changing needs of the veterans. They will address the unique needs of homebound, frail, disabling/chronic and/or dying veteran. All assessments will strongly integrate the values and goals of a Veteran and their family as they consider aging in the community with sufficient time spent on developing emergency plans based on individual Veteran resources and options. Referral to service providers Throughout the course of treatment, the social worker is the subject matter expert on VA and/or community resources. They 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. 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 on their own behalf, thus fostering a sense of independence and empowerment. Crisis Intervention 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, but VA and non-VA as available. 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. Education/Health promotion and prevention Incumbent 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. Incumbent has knowledge of medical terminology. Coordination of non-institutional and institutional services Incumbent is responsible for the coordination of the referrals of non-institutional services such as HBPC, ADHC/CADHC, HHA and home Hospice, in collaboration with the interdisciplinary treatment team members. The social worker is also responsible for the coordination of the referrals of institutional placements in Adult Homes, Assisted Living Programs, CNH or Long-term Nursing Home Placement. This includes reviewing the progress notes from the other providers to accurately determine the strengths and limitations of each veteran being referred for non-institutional and institutional alternatives. Social worker will educate the veteran, their families, and the team of all the options available to them and will collaborate with the veteran and family on the preferred option. Supportive Counseling The incumbent will provide the veterans and their caregivers with ongoing supportive counseling, with the ability to work with individuals from diversified backgrounds. The purpose of such counseling is to deal with the psychosocial impact of coping with chronic/disabling illness (es), onset of a catastrophic illness and/or dying, need for non-institutional or institutional services as needed during the veteran's enrollment in the HBPC Program. Work Schedule: Monday-Friday 8:00am-4:30pm Telework: Not Available Virtual: This is not a virtual position. Functional Statement #: 49501F

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/. 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). 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). Creditable Experience. The candidate must have knowledge of current professional social work practices. To be creditable, the experience must have required the use of knowledge, skills, abilities, and other characteristics associated with current professional social work practice. The experience or education must be post-Masters of Social Work (MSW) degree. Experience and education satisfying this requirement must be active professional practice, which is paid/non-paid employment as a professional social worker, as defined by the appropriate state licensing board. Quality of Experience. Experience is only creditable if it is obtained following graduation with a master's degree in social work and if it includes work as a professional social worker directly related to the position to be filled. Qualifying experience must also be at a level comparable to social work experience at the next lower level. Part-Time Experience. Part-time experience is creditable according to its relationship to the full-time work week. For example, one week of full-time credit is equivalent to two weeks of part-time work. Fellowships or Post-Graduate Training. Fellowship and post-graduate training programs are typically in a specialized area of clinical practice, i.e., group or family practice. Training as a fellow or post-graduate may be substituted for creditable experience on a year-for-year basis. Practicum in a VA Setting. A VHA practicum experience may not be substituted for experience, as the practicum (field placement) is completed prior to graduation with a master's degree in social work. 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. AND 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. 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. AND 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. An applicant with a current State Social Work License at Independent Practice Level and a valid, unrestricted driver's license is preferred. Reference: For more information on this qualification standard, please visit https://www.va.gov/ohrm/QualificationStandards/. Physical Requirements: Work is sedentary but also demands standing, walking, bending, twisting, and carrying light items.

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 Bronx VA Medical Center 130 West Kingsbridge Rd. Bronx, NY 10468 US
• Name: Kelli Bencic
• Phone: 716-458-6982
• Email: [email protected]