This Social Worker, Social Worker, Patient Aligned Care Team (PACT) position is within Social Work Services, VA Roseburg Health Care System in Roseburg, Oregon. The Social Worker, Patient Aligned Care Team (PACT) provides provides social work assessment, treatment/service planning, service delivery/interventions, case management and documentation of work. The Social Worker, Patient Aligned Care Team (PACT) assigned to Veterans in the PACT setting. Social work responsibilities include the assessment of psychosocial problems often at a time when the Veteran is experiencing crisis and include the provision of short-term, solution focused goal planning and case management with Veterans and/or their families. Referrals typically originate from members of the interdisciplinary team, from Veterans and/or their families presenting as walk-ins to seek assistance, and from community professionals. The incumbent must complete thorough assessments to determine the presenting problem, to determine in-home factors impacting the problem, and to determine obstacles to treatment and/or follow through with recommended treatments. Case management with members of the outpatient interdisciplinary team is provided in order to coordinate a collaborative effort to meet the agreed upon goals for a Veteran's treatment needs. Services include, but are not limited to, homelessness, hospice services, nursing home care, home health services, financial resources, VA benefits, and transportation services. Duties include but are limited to the following: Establishes and maintains effective therapeutic relationships with Veterans and/or their families in the PACT setting. The incumbent is able to independently work with Veterans and their families who are experiencing a wide range of complicated medical, psychiatric, emotional, behavioral, and psychosocial problems. Independently completes thorough psychosocial assessments to determine the psychosocial functioning and needs of Veterans and/or their families. Participates as a member of the interdisciplinary treatment team and collaborate with Veterans and Veteran family members to development and implement treatment/service plans and interventions. Possesses a working knowledge and experience in use of medical and mental health diagnoses, disabilities, and treatment procedures. This includes acute, chronic and traumatic illnesses, common medications and effects/side effects, and medical terminology. Facilitates action for community referrals/placements through collaboration with Veterans, Veteran families, and interdisciplinary treatment team members to ensure that appropriate community placements are completed in a timely manner. Serves as an advocate and liaison between Veterans and/or their families and VA and community resources in order to ensure thorough delivery of services. Possesses knowledge and ability to independently implement treatment goal planning, provide educational classes, and/or supportive groups for Veterans and families. Provides consultation and education to Veterans and their families regarding community resources, VA benefits and specialty programs, and advance directives. Provides consultation to other treatment team and staff members regarding psychosocial needs of Veterans and/or their families and the impact of the identified psychosocial problems on the Veteran's health care planning and compliance with treatment. Maintains knowledge of Veteran's benefits and services, community resources, and process for making appropriate referrals to community and other governmental programs or agencies. Possesses skills and knowledge to provide case management services to Veterans and their families throughout the continuum of care. Possesses and demonstrates ability to communicate effectively, both orally and in writing, with people from varied backgrounds. Serves on committees, work groups, and task forces at the facility as deemed appropriate by the supervisor and Chief of Social Work Services. Mindful of keeping their supervisor apprised of problems and recommended solutions to problems encountered in the incumbent's area of responsibility. Responsible for furthering one's own professional growth through continuing education and for ensuring continuing education appropriate to the area of assignment. Provides assistance with the orientation and learning of less experienced social workers and, if interested, to serve as a field instructor for social work students. Demonstrates knowledge and skill in the use of software applications for drafting documents and data management as well as other computer systems in use by the Veterans Health Administration. Maintains a level of productivity and quality consistent with the complexity of the assignment and consistent with social work standards, Joint Commission standards, and facility standards. Participates in a rotation of on-call social workers, including modification of tour of duty to accommodate patient care needs on weekends, as needed. Work Schedule: Monday - Friday, 8am to 4:30pm *possible on-call, evening and weekend rotation. 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.