Social Worker - Home Based Primary Care (HBPC)

Department of Veterans Affairs

The HBPC Social Worker is a member of a multidisciplinary team providing interdisciplinary primary care in the homes of Veterans with serious medical & psychosocial behavioral conditions for whom routine clinic based care is not effective or may not be possible. They provide intensive case management & caregiver support. They also collaborate with community partners & other professional agencies in care coordination & mobilization of tailored services for the Veteran or caregiver.

• Major duties include: Performs comprehensive initial and follow-up assessments to meet the psychosocial needs of the patient and their support systems. Independently uses evidence-based screening tools and assessments. Develops the psychosocial plan of care, following advanced assessment and screening, to improve the patient's ability to achieve optimal psychosocial functioning. Partners with the interdisciplinary team to enhance the Veteran's psychosocial treatment plan, experience, and progress toward treatment goals. Responsible for crisis intervention and/or suicide prevention in home environments & functions without additional staff support or supervision in patient homes. Performs rapid assessments and develops crisis management plans. Assess for suicidality and self-harm, perform appropriate interventions, and create a safety plan for the Veteran. Assist with admission to inpatient programs as needed. Provides case management services to Veterans and facilitates integration of varied services for the treatment of complex medical, psychosocial, rehabilitative, behavioral, or palliative care needs. Supports the Veteran and caregiver in coping with all aspects of chronic disease. Assess and intervenes to address caregiver burden. Completes documentation in accordance with applicable policy and standards. Provides Veterans with evidence-based individual, family, and group psychotherapy. Coordinates the delivery of psychosocial services and provides psychotherapy to assist Veterans in coping with complex and chronic illness, functional decline, changes in condition, adjustment, caregiver burden, and bereavement. Offers education and support and encourages the Veteran/family to advocate on their own behalf, fostering a sense of independence and empowerment in the Veteran. Act as an advocate, serving the best interest of the Veteran. Implements methods for measuring effectiveness of practice and utilizes measures to improve treatment services within the Geriatrics & Extended Care Service. Establishes and maintain positive working relationships with employees, volunteers, consumers, and stakeholders within the VA and with outside community agencies. Collaborates with other service providers in assessing the Veteran's needs. Offers education to the Veteran and caregiver on available services and assists them with referrals. Coordinates care with the Veteran, their caregiver, and other relevant parties through the continuum of care. Refer and connect the Veteran to needed services. Provides expert-level consultation on advance care planning, caregiver support, and aging-in-place resources. Provides orientation and coaching to new social workers and social work graduate students. Offers training to other staff in both formal and informal settings including team meetings, grand rounds, and continuing education offerings. Operates a government vehicle in the performance of their duties, and, subsequently must maintain medical clearance from the employee health department, have a valid state driver's license, and provide proof of insurability. Work Schedule: Monday-Friday; 8am-4:30pm Recruitment/Relocation Incentives (Sign-on Bonus): Not authorized Permanent Change of Station (Relocation Assistance): Not authorized Pay: Competitive salary and regular salary increases. When setting pay, a higher step rate of the appropriate grade may be determined after consideration of higher or unique qualifications or special needs of the VA (Above Minimum Rate of the Grade). Paid Time Off: 37-50 days of annual paid time offer per year (13-26 days of annual leave, 13 days of sick leave, 11 paid Federal holidays per year) Selected applicants may qualify for credit toward annual leave accrual, based on prior [work experience] or military service experience. Parental Leave: After 12 months of employment, up to 12 weeks of paid parental leave in connection with the birth, adoption, or foster care placement of a child. Child Care Subsidy: After 60 days of employment, full time employees with a total family income below $144,000 may be eligible for a childcare subsidy up to 25% of total eligible childcare costs for eligible children up to the monthly maximum of $416.66. Retirement: Traditional federal pension (5 years vesting) and federal 401K with up to 5% in contributions by VA Insurance: Federal health/vision/dental/term life/long-term care (many federal insurance programs can be carried into retirement) Telework: Not Available Virtual: This is not a virtual position. Functional Statement #: 92136-O Permanent Change of Station (PCS): Not Authorized

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