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    The Social Worker Home Based Primary Care serves as a core member of the interdisciplinary Home Based Primary Care (HBPC) treatment team. The incumbent works independently to provide expert level psychosocial interventions and case management services to veterans with complex medical, social and behavioral conditions in which routine clinic based care is not effective.

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    Patients served under the HBPC Program typically are those who have impaired mobility due to disability or functional limitation, inability to cope with the clinic environment due to cognitive, physical or psychiatric impairment, and the need for frequent coordinated interventions from multiple disciplines.

    Some of the primary duties for this position include but mot limited to the following:

    • Develops an assessment of the veteran in collaboration with the interdisciplinary treatment team, the veteran, family members and significant others, whenever possible. The goal of the assessment is to highlight the veteran's strengths, limitations, and internal/external supports and service needs in order to optimize the veteran's functional status and safely maintain the veteran in his/her home. The assessment will include a home visit.
    • Possesses the advanced practice skills to independently make a psychosocial diagnosis and offer psychosocial interventions, and then measures outcomes to interventions.
    • Participates and can lead weekly interdisciplinary care planning meetings when asked by the HBPC program director.
    • Ability to coordinate community-based services, including information and referral for additional services from other VA programs, other government programs and community agency programs. Has expert knowledge of veterans' benefits and services relating to special programs, service connected compensation, non-service connected pension. Facilitates and prioritizes referrals based upon veteran's needs and eligibility.
    • Provides education related to VA and community resources, entitlements, Advance Directives/Living Will and will refer veterans/families to the appropriate interdisciplinary team member for identified health education needs.
    • Independently identifies and prioritizes high-risk patients and provides case management services.
    • Provides crisis intervention services, seeking to address the cause as well as the presenting complaint, coordinates family conferences and serves as liaison to family members. Has working knowledge and experience in use of medical and mental health diagnoses, disabilities and treatment procedures. This includes acute, chronic and traumatic illnesses/injuries, common medications and their effects/side effects, and medical terminology.
    • Establishes and maintains effective therapeutic relationships with veterans and their families. Incumbent is able to independently work with patients and families who are experiencing a variety of psychiatric, medical and social problems utilizing individual, group and family counseling and therapy skills.
    • Possesses advanced knowledge and ability to independently implement treatment modalities, provide counseling or psychotherapy for individuals, families and groups.
    • Provides initial and annual caregiver burden assessment and provides individual counseling, resources, respite and general caregiver support as needed on a case by case basis.
    • Experienced in making rapid assessments and developing crisis management plans to maintain patient in the home, for admission to acute, short term and/or long term placements. Social worker utilizes advanced practice skills, professional judgment and expertise regarding the veteran's self care capability, family support system, and the veteran's health care needs and possible consequences.
    • Processes advanced knowledge and understanding of the laws and processes that protect the vulnerable elderly population, provide emergency mental health care and serve as liaison to community agencies charged investigating suspected abuse and neglect.
    • Independently provides consultation services to other staff regarding the psychosocial needs of veterans and the impact of psychosocial problems on health care and adherence to treatment plan.
    • Ability to evaluate incumbents own practice through professional peer review, case conferences and other organizational means. Incumbent is able to communicate effectively, both orally and in writing, with people from varied backgrounds.
    • Working knowledge and skill in the use of electronic medical record documentation, data management and other computer systems.
    • Enters all veteran/family contacts in the electronic record using appropriate formats and templates.
    • Periodically review and update documentation templates to ensure compliance with regulatory guidelines, social work standards of practice, and VHA policies.
    • Periodically review, update and write policies, procedures, and/or practice guidelines pertaining to the specialty population or specialty treatment program based on experience and evidence based practice research.
    The work will involve driving to veterans home with use of a government vehicle. The incumbent is occasionally asked to travel to a distant VA, training site or conference location.

    Work Schedule: Monday - Friday, 0730-1600, Anchorage
    Telework: May be available upon Supervisor approval
    Financial Disclosure Report: Not required

    Travel Required

    50% or less - You may be expected to travel for this position.

    Supervisory status


    Promotion Potential


  • Job family (Series)

    0185 Social Work

This job originated on www.usajobs.gov. For the full announcement and to apply, visit www.usajobs.gov/GetJob/ViewDetails/564619400. Only resumes submitted according to the instructions on the job announcement listed at www.usajobs.gov will be considered.