Social Worker (Home-Based Primary Care)

Summary Provides Veterans in the Home-Based Primary Care (HBPC) Program with high quality case management, clinical treatment, advocacy, and coordinate linkage with appropriate VA and community service providers and agencies as needed by the client. Services include psychosocial assessment of Veteran and family needs; individual, group and family counseling; caregiver burden assessments and intervention, and casework services for the purpose of addressing identified needs. Duties Total Rewards of a Allied Health Professional Functions Screening Assessment: Develop an assessment of the veteran in collaboration with the interdisciplinary treatment team, the veteran, family members, and significant others, whenever possible. Treatment Planning Goal Setting: Responsible for developing the treatment plan and setting achievable goals with the veteran and family in collaboration with the HBPC interdisciplinary treatment team members. Follows policies and procedures developed by Home & Community Based Services (HCBS), HBPC, and the Medical Center that are consistent with patient rights and the maintenance of the patient progress notes, outcomes, discharge, planning, and the patient's treatment plan. Referral to Service Providers: the Social Worker is a subject matter expert on VA and/or community resource throughout the course of treatment. Social Worker will collaborate with other service providers in reassessing the veteran's needs for non institutional, institutional service programs and entitlements. Responsible for educating the veteran and/or caregiver of the available services and assisting them in establishing the appropriate referrals based on the veteran's preference or that of his surrogate decision-maker. Resource Development: Responsible for developing a resource file of VA and community social service programs and will refer the veteran to needed services. Advocacy: When appropriate and feasible, social worker will educate and encourage the veteran/family to advocate on their own behalf, thus fostering a sense of independence and empowerment. Crisis Intervention: 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 provides education related to VA and community resources, entitlements, Advanced Directives/Living Wills, Durable Power of Attorney, Physician Orders for Life-Sustaining Treatment, and will refer veterans/families to the appropriate interdisciplinary team member for identified health education needs. Facilitates Complex Care Reviews or Care/Family conference as needed to collaborate and plan for complex needs of veterans with the interdisciplinary team, other professionals and services, and/or family. Responsible for the coordination of referrals of non-institutional services such as Adult Day Health Care (ADHC) or Community ADHC, home hospice, skilled and non-skilled homecare services in collaboration with the interdisciplinary treatment team members. Provides the veterans and their caregivers with ongoing supportive counseling. May participate as a member of

Hbpc QA

team. May include data collections and analysis, formulating plans to improve systems and re-evaluation of plan success. Social worker may be requested to conduct Community Nursing Home visits to assess the psychosocial needs of veterans in the community nursing home, and adequacy of care/services provided. Work Schedule: Monday-Friday, 8am-4:30pm Recruitment Incentive (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 #: 000000 Permanent Change of Station (PCS): Not authorized Qualifications NOTE: THE 2-PAGE

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To qualify for this position, applicants must meet all requirements within 30 days of the closing date of this announcement. 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. 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. Verification of the degree can be made by going to to verify that the social work degree meets the accreditation standards for a masters of social work. Licensure: Persons hired or reassigned to social worker positions in the GS-0185 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 Exception: VHA may waive the licensure or certification requirement for persons who are otherwise qualified, pending completion of state prerequisites for licensure/certification examinations. This exception only applies at the GS-9 grade level. For the GS-11 grade level and above, the candidate must be licensed or certified. At the time of appointment, the supervisor, chief social work or social work executive will provide the unlicensed/uncertified social worker with the written requirements for licensure or certification, including the time by which the license or certification must be obtained and the consequences for not becoming licensed or certified by the deadline. Failure to Obtain License or Certification: In all cases, social workers must actively pursue meeting state prerequisites for licensure or certification starting from the date of their appointment. Failure to become licensed or certified within the prescribed amount of time will result in removal from the GS-0185 social worker series and may result in termination of employment. Loss of Licensure or Certification: Once licensed or certified, social workers must maintain a full, valid, and unrestricted independent license or certification to remain qualified for employment. Loss of licensure or certification will result in removal from the GS-0185 social worker series and may result in termination of employment. English Language Proficiency: Candidates must be proficient in spoken and written English to be appointed as authorized by 38 U.S.C. § 7403(f). Grade Determinations: Social Worker, GS-9 Experience, Education, and Licensure: None beyond the basic requirements. Demonstrated Knowledge, Skills, and