Social Worker - Home Based Primary Care (HBPC)

The HBPC Social Worker is a member of a multidisciplinary team providing interdisciplinary primary care in the homes of Veterans with serious medical & psychosocial behavioral conditions for whom routine clinic based care is not effective or may not be possible. They provide intensive case management & caregiver support. They also collaborate with community partners & other professional agencies in care coordination & mobilization of tailored services for the Veteran or caregiver. Major duties include: Performs comprehensive initial and follow-up assessments to meet the psychosocial needs of the patient and their support systems. Independently uses evidence-based screening tools and assessments. Develops the psychosocial plan of care, following advanced assessment and screening, to improve the patient's ability to achieve optimal psychosocial functioning. Partners with the interdisciplinary team to enhance the Veteran's psychosocial treatment plan, experience, and progress toward treatment goals. Responsible for crisis intervention and/or suicide prevention in home environments & functions without additional staff support or supervision in patient homes. Performs rapid assessments and develops crisis management plans. Assess for suicidality and self-harm, perform appropriate interventions, and create a safety plan for the Veteran. Assist with admission to inpatient programs as needed. Provides case management services to Veterans and facilitates integration of varied services for the treatment of complex medical, psychosocial, rehabilitative, behavioral, or palliative care needs. Supports the Veteran and caregiver in coping with all aspects of chronic disease. Assess and intervenes to address caregiver burden. Completes documentation in accordance with applicable policy and standards. Provides Veterans with evidence-based individual, family, and group psychotherapy. Coordinates the delivery of psychosocial services and provides psychotherapy to assist Veterans in coping with complex and chronic illness, functional decline, changes in condition, adjustment, caregiver burden, and bereavement. Offers education and support and encourages the Veteran/family to advocate on their own behalf, fostering a sense of independence and empowerment in the Veteran. Act as an advocate, serving the best interest of the Veteran. Implements methods for measuring effectiveness of practice and utilizes measures to improve treatment services within the Geriatrics & Extended Care Service. Establishes and maintain positive working relationships with employees, volunteers, consumers, and stakeholders within the VA and with outside community agencies. Collaborates with other service providers in assessing the Veteran's needs. Offers education to the Veteran and caregiver on available services and assists them with referrals. Coordinates care with the Veteran, their caregiver, and other relevant parties through the continuum of care. Refer and connect the Veteran to needed services. Provides expert-level consultation on advance care planning, caregiver support, and aging-in-place resources. Provides orientation and coaching to new social workers and social work graduate students. Offers training to other staff in both formal and informal settings including team meetings, grand rounds, and continuing education offerings. Operates a government vehicle in the performance of their duties, and, subsequently must maintain medical clearance from the employee health department, have a valid state driver's license, and provide proof of insurability. Work Schedule: Monday-Friday; 8am-4:30pm Recruitment/Relocation Incentives (Sign-on Bonus): Not authorized Permanent Change of Station (Relocation Assistance): Not authorized Pay: Competitive salary and regular salary increases. When setting pay, a higher step rate of the appropriate grade may be determined after consideration of higher or unique qualifications or special needs of the VA (Above Minimum Rate of the Grade). Paid Time Off: 37-50 days of annual paid time offer per year (13-26 days of annual leave, 13 days of sick leave, 11 paid Federal holidays per year) Selected applicants may qualify for credit toward annual leave accrual, based on prior [work experience] or military service experience. Parental Leave: After 12 months of employment, up to 12 weeks of paid parental leave in connection with the birth, adoption, or foster care placement of a child. Child Care Subsidy: After 60 days of employment, full time employees with a total family income below $144,000 may be eligible for a childcare subsidy up to 25% of total eligible childcare costs for eligible children up to the monthly maximum of $416.66. Retirement: Traditional federal pension (5 years vesting) and federal 401K with up to 5% in contributions by VA Insurance: Federal health/vision/dental/term life/long-term care (many federal insurance programs can be carried into retirement) Telework: Not Available Virtual: This is not a virtual position. Functional Statement #: 92136-O Permanent Change of Station (PCS): Not Authorized

Applicants pending the completion of educational or certification/licensure requirements may be referred and tentatively selected but may not be hired until all requirements are met. Basic Requirements: United States Citizenship: Non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy. English Language Proficiency. Candidates must be proficient in spoken and written English to be appointed as authorized by 38 U.S.C. § 7403(f). Education. Have a master's degree in social work from a school of social work fully accredited by the Council on Social Work Education (CSWE). Graduates of schools of social work that are in candidacy status do not meet this requirement until the school of social work is fully accredited. A doctoral degree in social work may not be substituted for the master's degree in social work. Licensure. Persons hired or reassigned to social worker positions in the GS-185 series in VHA must be licensed or certified by a state to independently practice social work at the master's degree level. Current state requirements may be found by going to http://vaww.va.gov/OHRM/T38Hybrid/ May qualify based on being covered by the Grandfathering Provision as described in the VA Qualification Standard for this occupation (only applicable to current VHA employees who are in this occupation and meet the criteria). Grade Determinations: In addition to the basic requirements for employment, the following criteria must be met when determining the grade of candidates. Social Worker, GS-11 (1) Experience and Licensure. Appointment to the GS-11 grade level requires completion of a minimum of one year of post-MSW experience equivalent to the GS-9 grade level in the field of health care or other social work-related settings, (VA or non-VA experience) and licensure or certification in a state at the independent practice level. NOTE: For appointment licensure or certification at this level please refer to paragraph 3c. OR (2) Education. In addition to meeting basic requirements, a doctoral degree in social work from a school of social work may be substituted for the required one year of professional social work experience in a clinical setting. (3) Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, candidates must demonstrate all of the following KSAs: (a) Knowledge of community resources, how to make appropriate referrals to community and other governmental agencies for services, and ability to coordinate services. (b) Skill in independently conducting psychosocial assessments and treatment interventions to a wide variety of individuals from various socio-economic, educational, and other backgrounds. (c) Knowledge of medical and mental health diagnoses, disabilities and treatment procedures (i.e. acute, chronic and traumatic illnesses/injuries, common medications and their effects/side effects, and medical terminology) to formulate a treatment plan. (d) Skill in independently implementing different treatment modalities in working with individuals, families, and groups who are experiencing a variety of psychiatric, medical, and social problems to achieve treatment goals. (e) Ability to provide consultation services to new social workers, social work graduate students, and other staff about the psychosocial needs of patients and the impact of psychosocial problems on health care and compliance with treatment. (4) Full Performance Level Assignments. This is the full performance level. Social workers at this level are licensed or certified to independently practice social work. Incumbents are assigned to all program areas, including but not limited to: inpatient or outpatient medicine, surgery, mental health, neurology, rehabilitation medicine, and geriatrics. Employees provide professional, independent social work services in the assigned area.…