Senior Social Worker to serve in the Primary Care Patient Aligned Care Team

Job Description

Duties
Summary
The VA Sierra Nevada Health Care System is recruiting for a Senior Social Worker to serve in the Primary Care Patient Aligned Care Team (PACT) at the Fallon CBOC. The PACT team is a comprehensive team which delivers primary care to Veteran patients in a longitudinal rather than episodic fashon and which has as its focus: prevention; health promotion, coordination and chronic disease management.


Responsibilities
Clinical Functions:

Assessment of psychosocial problems that cause distress, often impacting the health condition and creating barriers to care.
Determine the underlying causes of the presenting problem(s), the interpersonal and environmental factors impacting the problem, and its effect on the patient's ability and desire to comply with the treatment recommendations by the multidisciplinary team.
Help patient and family to understand the contributing factors to the problem(s).
Coordinate with VA staff and community agencies to assist in problem solving as needed.
Appropriately utilize principles of human growth and development over the life span and will be able to assist Veterans in coping with the loss and grief experiences from disability and terminal illness.

Treatment:
Work Independently with Veterans and their families who are experiencing a wide range of complicated medical, psychiatric, emotional, behavioral, financial, legal holds and psychosocial problems.
Implement evidence-based treatment modalities, provide educational classes, and/or treatment groups for Veterans and families.
Determine effectiveness of treatment modality, progress toward identified goals and ability to determine when treatment is no long effective, needs to be modified, the veteran needs to be referred to another provided or specialty clinic and when termination of mental health treatment is appropriate.

PACT Case Management/Resource Referral:
Help the patient and family to understand the contributing factors to the problem(s), will discuss with them the pros and cons of possible short-term and long-term solutions, encouraging them to make positive and lasting changes to reduce stressors.
Will educate the veteran, their families and the team all the options available to them and will collaborate with the veteran and family on the recommendations, goals and preferred options.
Will coordinate with VA staff and community agencies to assist in the problem solving as needed.
Serves as the liaison between Veterans and/or their families and VA and community resources to ensure thorough delivery of services.

Crisis Intervention:
Make rapid assessments and develop crisis management plans for admission to mental health inpatient programs and immediate referral to resources.

Education/Health Promotion and Prevention:
Provide education related to VA and community resources, benefits, Advance Directives/Living Wills and will refer veterans/families to the appropriate interdisciplinary team member for identified health education needs.

Administrative Functions:
Responsible for supporting the mission, policies, and procedures of the VHA
Willing to serve on committees, work groups, and task forces at the facility as deemed appropriate.
Attend all appropriate Primary Care staff meetings, Social Work staff meetings and other meetings as identified by the Social Work Supervisor.

Other duties as assigned.

Contact: Kelly De Boer, Health Care Recruiter
Kelly.deboer@va.gov
775-223-5351

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