The interdisciplinary Home Based Primary Care (HBPC) treatment team is a specialized program under the administration of Geriatrics and Extended Care (GEC) Service Line. This position provides direct services to adult and geriatric Veterans enrolled in the HBPC Program with high quality case management, clinical treatment, advocacy, and to coordinate linkage with appropriate VA and community service providers/agencies as needed by the client. This position is physically located in either Kingman, AZ or Flagstaff, AZ based on the preference of the selectee. Pay will be adjusted based on the locality table for that area. Developing assessments of the Veterans in collaboration with the interdisciplinary treatment team, the Veteran, and family members/ significant others Contributing to the development of the treatment plan and setting achievable treatment goals with the Veteran, family members/significant others and other HBPC clinical staff Collaborating with other service providers in reassessing the Veteran's needs for non-institutional, institutional services/programs and entitlements Educating the Veteran and families/significant others 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 Developing crisis management plans and following the protocol of HBPC Program and Northern Arizona VA Health Care System Coordinating referrals of non-institutional services such as HBPC, ADHC/CADHC, home hospice and skilled and non-skilled homecare services in collaboration with the interdisciplinary treatment team members Providing Veterans and their caregivers with ongoing supportive counseling to deal with the psychosocial impact of coping with chronic/disabling illness, onset of a catastrophic illness and need for non-institutional or institutional services Incumbent will be required to assist with coverage in other NAVAHCS HBPC locations in times of Social Work staffing shortages (Kingman, AZ and Prescott, AZ) Work Schedule: Monday through Friday, 8:00 am to 4:30 pm Financial Disclosure Report: Not required
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