The VA Liaison for Health Care (hereinafter referred to as VA Liaison) is seen as the Veterans Health Administration (VHA) representative to the military installation and must represent the VA in all aspects of patient care, transfer, and outreach. The primary role of the VA Liaison is to ensure the transfer of health care, both inpatient and outpatient, from the Military Treatment Facility (MTF) to the appropriate VA health care facility. Major duties include, but are limited to: Working closely with the MTF treatment team, as an independent practitioner, using advanced practice skills and expertise to provide ongoing consultation regarding complex discharge planning issues, VA health care benefits, resources, and facilities. This requires an intimate knowledge of VHA programs and services nationwide, and the ability to match Veterans' needs with appropriate resources. Developing relationships and collaborating with the MTF social workers, nurses, case managers, managed care staff, and discharge planners to identify patients ready for discharge to a VA health care facility and to obtain clear referral information and authorization for VHA to treat those still on active duty. Meeting with the service member and/or family to provide education and an overview of VA health benefits and resources to address current medical and psychosocial issues identified as part of the service member's treatment plan. In collaboration with the MTF treatment team, the liaison must use advanced clinical skills to assess the patient and/or family's psychosocial situation, their ability to comprehend and comply with VA treatment plan that has been determined by the MTF staff and any special needs of the patient and/or family that may impact reaching optimal psychosocial functioning. Coordinating with the liaison's home VA health care facility Enrollment Coordinator to initially register active duty service members or enroll veterans at their facility utilizing the referral information. Registering active duty service members in the VA computer system eases transfer of care to the VA health care facility. Collaborating with MTF social workers, nurses and case managers to identify the VA health care facility where care will be transferred and an accepting physician at that facility. To ensure ease of registration or enrollment procedures, information is transmitted using PDX or Network Health Exchange (NHE) from the liaison's facility to the identified receiving VA health care facility. Identifying and communicating with the OEF/OIF Program Manager at the receiving VA health care facility to initiate and process referrals and linkages for transfers of care. Documenting all liaison activity in the Computerized Patient Record System (CPRS) in the nationally standardized templates that are available on the Health Information Management. Communicating the transfer plans to the patient and family while determining any unique patient or family needs requiring attention. Communicating ongoing needs of the patient and family to the receiving VA health care facility OEF/OIF Program Manager to further facilitate the seamless transition of care. Maintaining contact with the OEF/OIF Program Manager and with MTF staff, coordinating the transfer of care upon discharge from the MTF, and assisting in identifying and obtaining additional information needed from the MTF staff to optimize the transfer of care. Providing patient level referral and outcome information on all transfers of care from the MTF to the VA Liaison National Program Manager, Care Management and Social Work Service, Office of Patient Care Services (11CMSW), on a monthly basis through use of a spreadsheet, inputting summary information into an automated intranet workload report on a weekly basis, and attending regularly scheduled conference calls. Work Schedule: Monday - Friday; 8:00am - 4:30pm Telework: Not Available Virtual: This is not a virtual position. Position Title/Functional Statement #:Senior Social Worker (Liaison)/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.