Summary

The Home Based Primary Care (HBPC) Social Worker functions as a member of a multidisciplinary team, providing comprehensive, longitudinal, interdisciplinary, primary care in the homes of Veterans with serious medical, psychosocial, and behavioral conditions for whom routine clinic-based care is not effective or may not be possible.

Qualifications

Applicants pending the completion of educational or certification/licensure requirements may be referred and tentatively selected but may not be hired until all requirements are met.

Basic Requirements:

• The basic requirements for employment as a VHA social worker are prescribed by statute in 38 U.S.C. §
• 7402(b)(9), as amended by section 205 of Public Law 106-419, enacted November 1, 2000
• To qualify for appointment as a social worker in VHA, all applicants must meet the following: a
• Citizenship
• Be a citizen of the United States
• (Non-citizens may be appointed when it is not possible to recruit qualified citizens in accordance with chapter 3, section A, paragraph 3g this part)
• b
• Education
• Have a master's degree in social work from a school of social work fully accredited by the Council on Social Work Education (CSWE)
• Graduates of schools of social work that are in candidacy status do not meet this requirement until the School of Social Work is fully accredited
• A doctoral degree in social work may not be substituted for the master's degree in social work
• Verification of the degree can be made by going to http://www.cswe.org/Accreditation to verify that the social work degree meets the accreditation standards for a masters of social work
• c
• Licensure
• Persons hired or reassigned to social worker positions in the GS-0185 series in VHA must be licensed or certified by a state to independently practice social work at the master's degree level
• Current state requirements may be found by going to http://vaww.va.gov/OHRM/T38Hybrid/
• Physical Requirements
• See VA Directive and Handbook 5019, Employee Occupational Health Services, to include Operation of crane, truck, tractor, or motor vehicle English Language Proficiency
• Candidates must be proficient in spoken and written English to be appointed as authorized by 38 U.S.C. §
• 7403(f)
• Grade Determinations: Social Worker, GS-9 (1) Experience, Education, and Licensure
• None beyond the basic requirements
• (2) Demonstrated Knowledge, Skills, and Abilities
• In addition to the experience above, the candidate must demonstrate all of the following KSAs: (a) Ability to work with Veterans and family members from various socioeconomic, cultural, ethnic, educational, and other diversified backgrounds utilizing counseling skills
• (b) Ability to assess the psychosocial functioning and needs of Veterans and their family members, and to formulate and implement a treatment plan, identifying the Veterans problems, strengths, weaknesses, coping skills, and assistance needed
• (c) Ability to implement treatment modalities in working with individuals, families, and groups to achieve treatment goals
• This requires judgment and skill in utilizing supportive, problem solving, or crisis intervention techniques
• (d) Ability to establish and maintain effective working relationships and communicate with clients, staff, and representatives of community agencies
• (e) Fundamental knowledge of medical and mental health diagnoses, disabilities, and treatment procedures
• This includes acute, chronic, and traumatic illnesses/injuries
• common medications and their effects/side effects
• and medical terminology
• Social Worker, GS-11 (1) Experience and Licensure
• Appointment to the GS-11 grade level requires completion of a minimum of one year of post-MSW experience equivalent to the GS-9 grade level in the field of health care or other social work-related settings, (VA or non-VA experience) and licensure or certification in a state at the independent practice level
• NOTE: For appointment licensure or certification at this level please refer to paragraph 3c
• OR (2) Education
• In addition to meeting basic requirements, a doctoral degree in social work from a school of social work may be substituted for the required one year of professional social work experience in a clinical setting
• (3) Demonstrated Knowledge, Skills, and Abilities
• In addition to the experience above, candidates must demonstrate all of the following KSAs: (a) Knowledge of community resources, how to make appropriate referrals to community and other governmental agencies for services, and ability to coordinate services
• (b) Skill in independently conducting psychosocial assessments and treatment interventions to a wide variety of individuals from various socio-economic, cultural, ethnic, educational and other diversified backgrounds
• (c) Knowledge of medical and mental health diagnoses, disabilities and treatment procedures (i.e
• acute, chronic and traumatic illnesses/injuries, common medications and their effects/side effects, and medical terminology) to formulate a treatment plan
• (d) Skill in independently implementing different treatment modalities in working with individuals, families, and groups who are experiencing a variety of psychiatric, medical, and social problems to achieve treatment goals
• (e) Ability to provide consultation services to new social workers, social work graduate students, and other staff about the psychosocial needs of patients and the impact of psychosocial problems on health care and compliance with treatment
• (4) Full Performance Level Assignments
• This is the full performance level
• Social workers at this level are licensed or certified to independently practice social work
• Incumbents are assigned to all program areas, including but not limited to: inpatient or outpatient medicine, surgery, mental health, neurology, rehabilitation medicine, and geriatrics
• Employees provide professional, independent social work services in the assigned area
• Duties include but are not limited to: assessing and documenting identified behaviors or symptoms of abuse, neglect, exploitation and/or intimate partner violence
• use of clinical social work skills and knowledge to maintain Veteran privacy and confidentiality per policies, handbooks or directives
• and acts as an advocate with appropriate VA and community service providers and agencies when it serves the best interest of the Veteran and family members/caregiver
• Incumbent independently assesses the psychosocial functioning and needs of Veterans and their family members, identifying the Veteran's strengths, weaknesses, coping skills, and psychosocial acuity
• In collaboration with the Veteran, family/caregiver, and interdisciplinary treatment team, the social worker facilitates the delivery of health care services
• The social worker identifies family/caregiver stressors, conducts assessment and provides specific interventions
• The incumbent provides case management and care coordination to facilitate appropriate delivery of health care services, incorporates complex multiple causation in differential diagnosis and treatment of Veterans, including making psychosocial and psychiatric diagnoses within approved clinical privileges or scope of practice
• The social worker links the Veteran with services, resources, and opportunities, in order to maximize the Veteran's independence, health, and well-being
• The social worker conducts timely assessment of at-risk Veterans in crisis to identify immediate needs, evaluate risk, and initiate safety plan as appropriate
• Preferred Experience: Home Health experience, interdisciplinary team experience, and AHA Basic Life Support Certified
• Reference: For more information on this qualification standard, please visit https://www.va.gov/ohrm/QualificationStandards/
• The full performance level of this vacancy is GS-11
• The actual grade at which an applicant may be selected for this vacancy is in the range of GS-9 to GS-11.

Duties

• VA Careers - Social Work: https://youtube.com/embed/enRhz_ua_UU The HBPC social worker uses independent social work practice and intervention to treat the complex HBPC patient population
• These patients have complex chronic diseases that worsen over time
• The HBPC social worker's scope and function include the following: a
• Psychosocial Screening and Assessment
• The social worker uses knowledge and theories of mental health and aging to independently perform comprehensive initial and follow-up assessments to meet the psychosocial needs of the patient and their support systems
• Assessments include physical limitations, psychological/psychiatric needs, cognitive deficits, social and environmental milieus, -based approach focused on the Veteran's goals
• The social worker independently uses evidence-based screening tools and assessments
• b
• Psychosocial Treatment Planning and Goal Setting
• The social worker develops the psychosocial plan of care, following advanced assessment and screening, to improve the patient's ability to achieve optimal psychosocial functioning
• The social worker includes the Veteran's goals of care in the plan of care
• The patient-centered, plan of care may include individual and family counseling, long-term and advance care planning, non-pharmacological pain intervention, stress management, caregiver support, psycho-educational programming, and grief and bereavement counseling
• The social worker partners with the interdisciplinary team to enhance the Veteran's psychosocial treatment plan, experience, and progress toward treatment goals
• c
• Crisis Intervention
• The social worker is independently responsible for crisis intervention and/or suicide prevention in home environments
• The social worker functions without additional staff support or supervision in patient homes
• The social worker performs rapid assessments and develops crisis management plans
• Crises may include but are not limited to housing, finances, psychiatric relapse, suicidality, or violence
• The social worker will assess for suicidality and self-harm, perform appropriate interventions, and create a safety plan for the Veteran
• When responding to suicidality or a psychiatric emergency, the social worker will collaborate with first responders to ensure optimal home and pre-hospital care
• The social worker will assist with admission to inpatient programs as needed
• The HBPC social worker follows applicable protocols when responding to medical or psychological emergencies
• d
• Case Management/Outreach
• The HBPC social worker provides case management services to Veterans and facilitates integration of varied services for the treatment of complex medical, psychosocial, rehabilitative, behavioral, or palliative care needs
• The HBPC social worker achieves desired outcomes through longitudinal and comprehensive care, and coordinated hospital, home, and community-based services
• The social worker supports the Veteran and caregiver in coping with all aspects of chronic disease
• The social worker assesses and intervenes to address caregiver burden
• e
• Documentation/Productivity
• The HBPC social worker completes documentation in accordance with applicable policy and standards
• The social worker maintains an acceptable level of productivity and performs other duties as assigned
• Work Schedule: M -F: 7:30am - 4:00pm or 8:00am - 4:30pm Telework: Not Authorized Virtual: This is not a virtual position
• Functional Statement #: 000000 Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): not Authorized