The social worker provides psychosocial clinical care to Veterans participating in the Mental Health Intensive Case Management (MHICM) program. The social worker serves as the primary contact and liaison for Veterans directly assigned to them for care within the community. The social worker is responsible for having working knowledge of all Veterans participating in the MHICM program so that cross-coverage can be provided whenever required through the use of a shared caseload model. The social worker will complete a psychosocial assessment of the Veteran, family, economic, community, and psychosocial support systems within 30 days upon entering the MHICM program. The assessments must reflect a high level of skill in gathering, analyzing, interpreting, and documenting data that is pertinent and directly related to patient health care planning, treatment, education and case management. The Veteran, family members and significant others are involved in this process, 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 to help ensure that the Veteran is able to safely live in the least restrictive environment possible. The social worker will update the psychosocial assessment annually or as clinically warranted. The social worker will function as a case manager for Veterans in the MHICM program performing duties to facilitate independent community living by coordinating mental health and community care. The social worker will also provide oversight of continuity of care/healthcare appointments to ensure sustainability of independent living. The social worker will respond to consults as determined by the program coordinator by utilizing a screening tool and other measurement devices while assessing the Veteran's emotional, functional, and psychological condition. The social worker may present the findings to the MHICM team and program coordinator to determine rejection or acceptance into the program. The social worker is responsible for contributing to the treatment plan, and setting achievable treatment goals with the Veteran/family in collaboration with the MHICM interdisciplinary treatment team members. The social worker will include psychosocial problems in the treatment plan and will attend interdisciplinary care planning meetings. Ongoing assessments and updating treatment plans are done when necessary or on a quarterly basis given the changing needs as health status changes. The social worker also assists Veterans in completing measurement based care screenings to inform the treatment planning process. The social worker assists Veterans to (1) adjust to current living situation, (2) explore areas of deficit in activities of daily living, (3) provide and/or arrange skill building educational activities (4) explore potential areas of healing for psychosocial conflicts or trauma by using a "Recovery Model" based approach. Throughout the course of treatment, the social worker is the subject matter expert on VA and/or community resources. The social worker will collaborate with other service providers in reassessing the Veteran's needs for additional resources in support of the Veteran's recovery. The social worker will act as an advocate when it serves the best interest of the Veteran/family. When appropriate and feasible, social worker will educate and encourage the Veteran/family to advocate for themselves, thus fostering a sense of independence and empowerment. The social worker will assist MHICM Veterans in the preparation of materials needed for applications to various agencies for entitlements, and then follow the process of the application until a determination has been made. The social worker is experienced in making rapid assessments and developing crisis management or suicide prevention safety plans. The social worker routinely completes mental health triage, safety plans and suicide risk evaluations annually or as clinically indicated. The social worker will provide 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. The social worker serves as the discharge coordinator for Veterans participating in the MHICM program, and will serve as a liaison with inpatient or residential treatment teams to ensure seamless reintegration back into the community. The social worker will continuously assess the acuity and need for intensive case management services and utilize appropriate discharge options as clinically indicated. The social worker will enter all Veteran/family contacts in the electronic record using appropriate templates, encounter forms, clinics and social work approved CPT codes. This information will be entered in a complete, confidential, and professional manner to insure information on the patient is shared with other VA staff. The incumbent completes clinical reminders and facilitates further intervention for positive clinical screens. The incumbent completes all required NEPEC data forms as required by policy. Other duties as assigned Work Schedule: Monday - Friday, 8:00 am - 4:30 pm Financial Disclosure Report: Not required
Providing Health Care for Veterans: The Veterans Health Administration is America’s largest integrated health care system, providing care at 1,255 health care facilities, including 170 medical centers and 1,074 outpatient sites of care of varying complexity (VHA outpatient clinics), serving 9 million enrolled Veterans each year.