The Social Worker, Home Based Primary Care (HBPC), works within the Rehabilitation and Long-Term Care (RLTC) Division at the VA Portland Health Care System in Vancouver, Washington. The Social Worker is assigned to Home Based Primary Care (HBPC) in the Home and Community Based Services Department (HCBS) within the Rehabilitation and Long-Term Care (RLTC) Division at the VA Portland Health Care System in Vancouver, Washington. The HBPC mission is to provide comprehensive, longitudinal primary care by an interdisciplinary team in the homes of Veterans with chronic disabling diseases for whom clinic-based care is not effective. The primary focus of HBPC is longitudinal home care for Veterans who require interdisciplinary health care teams, continuity, coordination of care, and the integration of diverse services to cover their complex medical, social, and behavioral care needs.Duties include but are not limited to the following: Screening/Assessment - Develops an assessment of the Veteran in collaboration with the interdisciplinary treatment team, the Veteran, and, whenever possible, family members and significant others. The goal of the assessment is to highlight the Veteran's strengths, limitations, and internal/external supports and service needs to optimize the Veteran's functional status and safely maintain the Veteran in his/her home. The assessment will include a home visit. Treatment Planning/Goal Setting - The social worker is responsible for developing the social work treatment plan and setting achievable and measurable treatment goals with the Veteran and/or family in collaboration with the HBPC interdisciplinary treatment team members. The social worker will include mental health and psychosocial problems onto the interdisciplinary treatment plan. The social worker will attend weekly interdisciplinary care planning meetings. Provision of Mental Health Assessment/Services in the Home - HBPC social workers will provide treatment planning for mental illness and psychosocial challenges which includes diagnosis, individual psychotherapy, and supportive counseling to be provided in the Veteran's home. Referral to Service Providers - 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 non-institutional services/programs, institutional services/programs, and entitlements. Resource Development - The social worker is responsible for developing a resource file of VA and community social service programs and will refer the Veteran to needed services. Advocacy - The social worker understands the intimidation of bureaucracy and will act as an advocate when it serves the best interest of the Veteran and/or family. When appropriate and feasible, the social worker will educate and encourage the Veteran and/or family to advocate on their own behalf, thus fostering self-determination, independence, and empowerment. Crisis Intervention - The social worker is experienced in making rapid assessments and developing crisis management plans to maintain the patient in the home, for admission to acute, short term, and/or long-term placements. Education/Health Promotion and Prevention - The social worker provides education related to VA and community resources, entitlements, Advance Directives/Living Will and will refer Veterans and/or families to the appropriate interdisciplinary team member for identified health education needs. Coordination of Non-Institutional and Institutional Services - The social worker is responsible for the coordination of the referrals to non-institutional HCBS programs in collaboration with the interdisciplinary treatment team members. The social worker is also responsible for the coordination of the referrals of institutional placements in Adult Homes, Assisted Living Programs, CNH, orVA-CLC. Supportive Counseling - The social worker will provide Veterans and their caregivers with ongoing supportive counseling. The purpose of such counseling is to deal with the psychosocial impact of coping with chronic/disabling illness(es), onset of a catastrophic illness and/or dying, and need for non-institutional or institutional services as needed during the Veteran's enrollment in the HBPC Programs. Administrative Responsibilities - The social worker will enter all Veteran and/or family contacts in the electronic record using appropriate formats and templates. The social worker will attend all meetings (regularly scheduled interdisciplinary treatment team meetings, monthly HBPC Mental Health Team Meetings), as well as other mandatory meetings as announced, and perform other duties as required by the HBPC program. Work Schedule: Monday - Friday; 7:30am to 4pm or 8am to 4:30pm Telework: Not available. Virtual: This is not a virtual position. Position Title/Functional Statement #:Social Worker - Home Based Primary Care (HBPC)/PD000000 Relocation/Recruitment Incentives: Not authorized. Permanent Change of Station (PCS): Not authorized. 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.