The General Caregiver Support Program Social Worker is assigned to the General Caregiver Support Program with primary responsibilities to provide clinical evidence-based services and interventions; provide caregiver, Veteran and staff education on caregiver issues; engage in community outreach and resource development; continuous quality-improvement activities, and evaluation/consultation Screening and Assessment Independently conducts psychosocial assessments, within program prescribed timeframes, to include the Veteran's strengths, limitations, internal/external supports, and service needs in order to optimize the Veteran's functional status and safely maintain the Veteran in their preferred living situation. Participates in direct caregiver and Veteran contacts to identify and assess caregiver stress/burden and the development and application of directed clinical treatment interventions. Applies a working knowledge and experience in use of medical and mental health diagnoses, disabilities and treatment procedures for acute, chronic, and traumatic illness/injuries, common medications including their effects and side effects, non-pharmacological pain interventions, stress management, and, medical terminology. Applies knowledge of social determinants of health to the assessment of need and risk. Evaluates the acuteness of need for psychosocial intervention and case management services based on high risk factors such as suicide, intimate partner violence, adult abuse/neglect, food insecurity, homelessness, terminal illness, competency/guardianship, and other acute psychosocial stressors. Identifies the need for adaptive equipment and works with the interdisciplinary team to coordinate. Assesses for home health and non-institutional care needs. Assessments identify psychosocial issues impacting the patient/caregiver's ability to achieve optimal outcomes and implementing interventions. Based upon the assessment, social work case management addresses psychosocial needs and supports patient driven goals of care. Treatment Planning and Case Management Develops achievable Veteran centric care/treatment plans and discharge plans (when indicated) in collaboration with the interdisciplinary treatment team, the Veteran, and family members/significant others. Addresses the unique needs of the Veteran including, homebound, frail, disabling/chronic conditions, end of life needs, and food insecurity. Is responsible for educating the Veteran and/or caregiver of the availability of services and assist them in accessing appropriate/preferred resources. Will complete ongoing assessments and update treatment plans at prescribed intervals or as clinically indicated. Participates in the development of the individual plan of care at interdisciplinary care meetings for assigned panel of patients. Resource Referral/ Development Serves as the subject matter expert on VA and community resources, collaborating with other services providers. The incumbent serves as a consultant for navigating the complex processes caregivers, Veterans, and families encounter when interacting with government and community agencies. Applies their general knowledge of Veterans' benefits and services related to special programs, service connection compensation, and non-service connected pension to assist with application processes and referrals. Develops a resource file of VA and community resources and collaborates with other VA social workers to keep the file comprehensive and current. Coordinates community-based services, including information and referral for services from other VA programs, other government programs, and community agency programs. Facilitates referrals based upon Veteran need and eligibility, as well as, refers eligible Veterans for non-institutional care. Crisis Intervention Provides crisis intervention services, seeking to address causation as well as presenting complaints. Makes rapid assessments and develop crisis management plans to return Veterans to a state of homeostasis including maintaining Veteran in the home, admission to acute, psychiatric, or short term/long term placements. In the event of a medical or psychiatric emergency, the incumbent follows the Caregiver Support Program or facility protocols. Establishes and maintains effective therapeutic relationships with Veterans and their families. Education/Health Promotion and Prevention Provides education related to VA and community resources, entitlements, and care/end of life planning. Participates in facility outreach activities in order to disseminate needed information to Veterans, VA staff, and community agencies to strengthen service linkages. Advises and collaborates with interdisciplinary teams throughout the medical center on caregiver issues. The incumbent creates education tools, develops programs and implements training focused on specific caregiver needs/issues. Advocacy Delivers service from a Veteran-centric perspective and acts as an advocate on behalf of the Veteran when it serves the best interest of the Veteran/family. Work Schedule: Fulltime. Normal working hours are M-F, 8:00am-4:30pm Financial Disclosure Report: Not required Virtual: No Telework: Yes Compressed/Flexible Schedule: Yes Relocation/Recruitment Incentive: No
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.