This position is located within the Social Work Service at the San Antonio VHA, Audie L. Murphy Medial Center. This position provides direct services to adult and geriatric Veterans enrolled in the Home-Based Primary Care (HBPC) program. This position is responsible for assessment, planning, and provision of case management services in the HBPC Program. Duties include but are not limited to: Develop an assessment of the Veteran in collaboration with the interdisciplinary treatment team, the Veteran, and family members/significant others, whenever possible. Responsible for 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. Subject matter expert on VA and/or community resources. Collaborate with other service providers in reassessing the Veteran's needs for non-institutional, institutional services/programs and entitlements. Responsible for 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. Responsible for using the current Social Work resource file of VA and community social service programs and enhancing the content to the benefit of Veterans. Act as an advocate when it serves the best interest of the Veteran and family members/significant others. Educate and encourage the Veteran to advocate on his/her own behalf, thus fostering a sense of independence and empowerment. Provides education related to VA and community resources, entitlements, Advance Directives/Living Will and will refer Veterans and families/significant others to the appropriate interdisciplinary team member for identified health education needs. Responsible for the coordination of the 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. Responsible for the coordination of the referrals of institutional placements in Adult Homes, Assisted Living Programs, CNH or VA Community Living Center. This includes reviewing the progress notes from the other providers to accurately determine the strengths and limitations of each Veteran being referred for non-institutional and institutional alternatives. Provide the Veterans and their caregivers with ongoing supportive counseling. Establish and maintain positive working relationships with employees, volunteers, consumers and stakeholders within the VA and outside community agencies. Other duties as assigned Work Schedule: Monday -Friday 8:00-4:30 Telework: Not Available Virtual: This is not a virtual position. Position Title/Functional Statement #:Social Worker/PD000000 and 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.