The Social Worker is assigned to Home Based Primary Care (HBPC) in the Home and Community Based Services Department (HCBS). The HBPC Social worker is assigned to the Salem CBOC and provides services to Veterans in their homes in the areas surrounding the assigned CBOC. 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. The incumbent provides Veterans in the HBPC Program with high quality case management, clinical treatment, advocacy, and coordinates linkages with appropriate VA and community service providers and/or agencies, as needed, to maximize function, optimize health, minimize institutionalization, and maintain quality of life. Services provided include both short- and long-term interactions through the HBPC program including local and rural HBPC teams and is accomplished in collaboration with other members of the HBPC interdisciplinary treatment teams. Other duties will include, but are not limited to: The social worker will develop 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. It is the responsibility of the social worker, working within the interdisciplinary treatment team, to develop a treatment plan with the Veteran based on this assessment. The assessment will include screening for mental health, substance abuse, and psychosocial problems, which identified, affect treatment planning and goal setting for Veterans, family members, significant others, support systems, and Veteran's interdisciplinary treatment team. 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. Ongoing assessments and updating treatment plans are done when necessary or on a quarterly basis given the Veteran's changing needs as biopsychosocial needs change. Social workers will address the unique needs of homebound, frail, disabling/chronic, and/or dying Veterans. Social workers will identify and address needs, determine treatment plans, and collaboratively set goals with Veterans with mental illness, substance abuse issues, and psychosocial challenges. Social workers work collaboratively with Veterans, their families, significant others, and their support systems. Work Schedule: Mon-Fri, 7:30AM-4:00PM OR 8:00AM-4:30PM Financial Disclosure Report: Not required
Internal Number: 599636900
About Veterans Affairs, Veterans Health Administration
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.