The Social Worker is assigned to the Intensive Management Patient Aligned Care Team (IMPACT) Program serving SFVAHCS primary care clinics and the Community Based Outpatient Clinics CBOCs. The IMPACT team serves as an adjunctive arm of each PACT. The IMPACT team works to extend PACT support into the community setting and may provide extended hours to address the needs of patients referred. This includes those with high CAN scores. This may include high utilizers who are at the highest risk of hospitalization or death. This may include a modified tour of duty.Learn more about this agency
Work Schedule: Monday - Friday, 8:00am - 4:30pm
Financial Disclosure Report: Not required
The role of the Social Worker is to provide community based social work services to the Veteran and family/support system when indicated and to collaborate and communicate with the Veteran, support system, IMPACT and primary PACT teams and/or Mental Health Treatment Coordinator (MHTC) to assess, intervene and promote implementation of a unified, comprehensive treatment plan. The goal is stabilization, decrease in high utilization and increase Veteran/provider satisfaction. Social work activities include: home visit; assessing and monitoring coping in the community including identifying and responding to crisis and risk; accompanying Veterans to appointments in the community that facilitate linkage to support services and benefits; identifying need for and facilitating transition to higher levels of care when indicated; and visits via telehealth.
76% or greater - Travel will include home visits, visits to community agencies, visits to care giving facilities in the community etc., depending on the incumbent's specific assignment.
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This job originated on www.usajobs.gov. For the full announcement and to apply, visit www.usajobs.gov/GetJob/ViewDetails/496708800. Only resumes submitted according to the instructions on the job announcement listed at www.usajobs.gov will be considered.