CRH Social Worker - Collaborative Care Manager (PCMHI)

Department of Veterans Affairs

The CRH PCMHI Collaborative Care Manager (PCMHI CoCM) Social Worker (SW) provides evidence-based, condition specific (e.g., depression), protocol-driven services to collaboratively assist providers in treating common mental health and health behavior concerns in primary care. PCMHI CoCM services include patient education, activation, behavioral interventions, monitoring of medication adherence and response, as well as other protocol-driven services.

• Total Rewards of a Allied Health Professional The VISN Clinical Resource Hub (CRH) Social Work Collaborative Care Management (CoCM) position is a VISN based position located in legacy VISN 2. This position falls under the general supervision of the VISN 2 CRH Psychology Section Chief. A Clinical Resource Hub is a repository of clinical and administrative staff that serve Veterans Affairs facilities within a Veterans Integrated System Network (VISN). Staff are hired by the CRH to provide interprofessional services to VISN facilities that are underserved or experiencing gaps in clinicians due to the inability to match provider supply with demand. VA Video Connect (VVC) is the primary modality for treatment, although this position may require travel to VISN medical centers or Community Based Outreach Clinics (CBOC). The PCMHI Collaborative Care Manager (PCMHI CoCM) Social Worker (SW) provides evidence-based, condition specific (e.g., depression), protocol-driven services to collaboratively assist providers in treating common mental health and health behavior concerns in primary care. PCMHI CoCM services include patient education, activation, behavioral interventions, monitoring of medication adherence and response, as well as other protocol-driven services. These services are provided by CRH to facility outpatient Primary Care settings within a collaborative, interdisciplinary model. The Social Worker will work under the Mental Health Careline The PCMHI CoCM SW is an integral part of the CRH PCMHI team. Duties may include: Patient outreach and engagement in treatment Patient contact may be provided via telephone and written correspondence, however face-to-face virtual care is within the scope of this position with VVC as the primary modality of care delivery Initial assessment of the Veteran, including the following: Administration of validated patient reported outcome measure Review of assessments and documentation completed by others Obtain missing pertinent information from providers, patients, and medical records Development of an individualized treatment plan using standardized algorithms to guide treatment recommendations and support evidence-based decision making Keep current with knowledge of the variety of clinical options available through the medical center and local community about how to refer/engage Veterans Review of initial assessment and treatment plan with the PCMHI Provider with Prescribing Privileges consultant and PCP, incorporating modifications of the plan as recommended Routine use of a patient registry as indicated Participation in weekly caseload consultation with the consulting PCMHI Provider with Prescribing Privileges Providing education and brief interventions using evidence-based techniques such as behavioral activation, motivational interviewing, and other focused treatment strategies Monitoring of Veteran progress using validated patient reported outcome measures Ongoing review of progress and recommendations for changes in treatment, including medication adjustments, utilizing evidence-based algorithms in consultation with the PCMHI Provider with Prescribing Privileges Relapse prevention planning throughout care, including transition from active treatment to maintenance as goals are achieved Timely and thorough documentation of all patient interactions Provision of same-day access to PCMHI CoCM services Ongoing collaboration with and coordination of the Veteran's care with the treating PCP and other healthcare professionals Influence adherence to evidence-based treatment guidelines in PACT by providing "on-time, on-target" information to PACT providers Function effectively within interdisciplinary teams, fostering open communication, mutual respect, and shared decision-making to achieve quality patient care Continuously collaborate with the entire PCMHI team to ensure high quality, effective, Veteran-centered services at the patient and programmatic levels. Collaborate with PCMHI leadership/team members to develop/enhance educational materials and use marketing strategies to promote PCMHI CoCM services. Effectively communicate with patients, families, caregivers, VA leadership, and members of the interdisciplinary team Work Schedule: Monday - Friday ((8:00am - 4:30pm) Recruitment/Relocation Incentives (Sign-on Bonus): Not Authorized Permanent Change of Station (Relocation Assistance): Not Authorized Telework: May be available Virtual: This is not a virtual position. Permanent Change of Station (PCS): Not Authorized

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