Social Worker (PACT)

Department of Veterans Affairs

The Patient Aligned Care Team (PACT) Social Worker is located at the North East Bexar VA Clinic and is part of a comprehensive team which delivers primary care to Veterans in either a longitudinal or episodic fashion, which has its focus on the following: prevention, health promotion, psychoeducation, care coordination, direct clinical services, and chronic disease case management. The Social Worker assigned to PACT can be assigned to different Primary care areas.

• Duties may include but are not limited to: The incumbent has the primary responsibility to assist PACT Veterans with navigating care, facilitating access to care, and follow-up with the PACT team to ensure appropriate care is being provided; Serves as the liaison between community agencies and VA providers; Complete psychosocial assessments and coordinate care to facilitate the most appropriate delivery of health care services, while linking the Veteran and/or their families with services, resources and opportunities in order to maximize their knowledge, independence, health and well-being; Identifies family/caregiver stressors and conducts assessments and provides specific interventions or referrals on their behalf. The incumbent will determinate appropriate level of case management being offered based on Veterans' level of acuity for Veterans' psychosocial circumstances; Completes assessments timely for at-risk Veterans in crisis to identify immediate needs, evaluate risk, and initiate safety plans in consultation with their supervisor; Establish and maintain professional interactions and relationships with stakeholders both within the VA and the community; Act as a consultant to other team/staff members in regard to different Social Work program areas; Provide education for the Veteran on how to get assigned a PACT provider; Complete assessments via phone, VVC, or face to face; Provide case management to Veterans with high care assessment need (CAN) scores or other complex needs; Uses clinical social work skills and knowledge to maintain Veteran privacy and confidentiality per policies, handbooks or directives; Assess and document identified behaviors or symptoms of abuse, neglect, exploitation and/or intimate partner violence; Serve on committees, work groups, and task forces at the facility and/or Veterans Integrated Service Network (VISN) level and/or in the community; Knowledge of the PACT team approach and the role of each health and allied health care team members, as well as an understanding of the role of the Social Worker in the PACT model. This incumbent will be able to identify contributing factors of homelessness, discharge planning, placement/treatment options in the community, and referrals for non-institutional services; Facilitates action for community placements through collaboration with Veterans and their families, as well as interdisciplinary treatment team members to ensure that appropriate community placements are completed in a timely manner; Provides education to Veterans and families in regard to My HealtheVET, Whole Health program, and Community Care options; Provides consultation to other treatments teams and staff members regarding psychosocial needs of Veterans and/or their families and the impact of the identified psychosocial problems on the Veteran's health care planning and compliance with treatment; Educate Veterans regarding VA benefits and VA services, community resources, and process for making appropriate referrals to community and other governmental programs or agencies; Utilize and promotes group, individual, and phone education to complete Advance Care Planning (ACP) and/or Advance Directives in the PACT clinic; Responsive to consults within established time frames and actively works to meet Veteran's psychosocial needs through face to face, phone or telehealth appointments; Educates Veterans on the use of VA Virtual/Video Connect (VVC) clinics effectively; Follows STVHCS standard operating procedures for evaluating and mitigating suicide risk to include: Completes the Columbia Suicide Severity Risk Scale (C-SSRS) annually or more often as indicated, the Comprehensive Suicide Risk Evaluation, and a Safety Plan via shared template in the Computerized Patient Record System (CPRS) on all patients at intake, with Veterans with suicidal ideation and on any Veteran whose record is flagged "High Risk for Suicide." Additionally, completes the Suicide Behavior and Overdose Report (SBOR) as clinically indicated. All clinical decisions will be discussed with clinical supervisor while the incumbent is under supervision; Will include coverage for outpatient clinics and unassigned Veterans. This position may be assigned to cover clinics within the STVHCS and be required to work at location of clinics during coverage; Performs other duties as assigned. Work Schedule: Monday - Friday, 7:30am to 4:00pm or 8:00am to 4:30pm Telework: Ad-hoc only, as determined by the agency policy. Virtual: This is not a virtual position. Functional Statement #: 53793-F; 53794-F Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized

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