The incumbent is assigned to the Extended Care and Rehabilitation Service Line. Responsibilities include the management, coordination and provision of social work services to residents and their families in the CLC setting. In the provision of care to residents whose ages range from young adulthood to elderly adulthood, the social worker recognizes the age related needs and demonstrates knowledge and care appropriate to that age group. Major Duties of this position include but are not limited to: The incumbent will provide orientation to new residents of the CLC, communicating with Veterans and family members/significant others the purpose of CLC, expected length of stay and goals for discharge on admission to the CLC. The incumbent will conduct biopsychosocial assessments to determine needs of Veterans and family members. The incumbent is an active participant in the treatment planning process with other disciplines. The incumbent will facilitate the Long Term Care Co-Pay process with the Veteran and family members. The incumbent will participate in discharge planning with other disciplines, and Veterans and family members to the least restrictive environment through shared decision making, and will be responsible for ensuring that discharge plans are executed in a manner that is timely and appropriate. The incumbent will provide consultation/education to Veterans and families on community resources, and VA services and benefits. The incumbent will act as a consultant to other team/staff members. The incumbent will act as liaison between VA and community resources. The incumbent will provide case management to Veterans and families, as needed, throughout the continuum of care. The incumbent will provide a full range of social work services within commonly accepted standards of social work practice which includes case management, individual, family and group counseling, discharge planning, vulnerable adult reporting, and other services as appropriate. The incumbent will provide psychosocial treatment to assist Veterans and family members with psychosocial concerns. This may include financial, legal, housing, and other issues that can impact on health and functioning. It also includes helping Veterans cope with new diagnoses, declining functioning, limitations on functioning, and death. Guiding principles are to promote health and wellness and move care forward for the well-being of the Veteran. The incumbent will assist Veterans with crisis situations as required. The incumbent will serve as the CLC contact person with family members and significant others, and will coordinate family conferences and meetings and address family issues that impact the Veteran's health and functioning. The incumbent will serve as an advocate for residents with facility staff and treatment team members, and will help other team members understand the Veteran's perspective, life situation, coping mechanisms, and psychosocial problems. The incumbent will assist Veterans address advance care planning and end-of-life issues, including advance directives, living wills, pain management, dying and the transition to palliative and hospice care. The incumbent will provide wellness/prevention education and facilitate resident/family support groups as appropriate. The incumbent will as appropriate, supervise the practice of social work students, or a less experienced social worker. The incumbent will coordinate treatment and communicate with the care lines to facilitate continuity of care for veterans. The incumbent will participate in various Service Line or health care system workgroups, committees, and/or councils to represent and contribute social work expertise as assigned. .The incumbent will maintain data and statistical compilations to comply with Joint Commission, VA and health care system policy and procedures. The incumbent will document all social work interventions and activities in the resident's clinical record utilizing CPRS and ensure appropriate hand off when transferring patient care. This independent documentation includes the initial biopsychosocial assessment, periodic reassessments (at least quarterly or as changes in the resident's condition occur), review of progress towards problem resolution and treatment goals/outcomes, regular progress notes and a closing or discharge summary. Actively participate in completing designated section or sections for the Minimum Data Set. Work Schedule: Monday through Friday, 0800am to 1630pm Telework: Not Eligible Virtual: This is not a virtual position Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized Financial Disclosure Report: Not required
Providing Health Care for Veterans: The Veterans Health Administration is America’s largest integrated health care system, providing care at 1,255 health care facilities, including 170 medical centers and 1,074 outpatient sites of care of varying complexity (VHA outpatient clinics), serving 9 million enrolled Veterans each year.