Job Description

Summary

The Patient Aligned Care Team (PACT) is a comprehensive team which delivers primary care to veteran patients in a longitudinal rather than episodic fashion and which has as its focus: prevention; health promotion - coordination - and chronic disease management. The social worker functions as a PACT teamlette member with a panel of veterans to ensure that health care meets their needs - as defined by the veteran.

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:

• United States Citizenship: Non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy
• 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 to verify that the social work degree meets the accreditation standards for a Master of Social Work
• 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
• Exception
• VHA may waive the licensure or certification requirement for persons who are otherwise qualified - pending completion of state prerequisites for licensure/certification examinations
• This exception only applies at the GS-9 grade level
• For the GS-11 grade level and above - the candidate must be licensed or certified
• At the time of appointment - the supervisor - chief social work or social work executive will provide the unlicensed/uncertified social worker with the written requirements for licensure or certification - including the time by which the license or certification must be obtained and the consequences for not becoming licensed or certified by the deadline
• For appointments at the GS-9 grade level - VHA social workers who are not licensed or certified at the time of appointment must become licensed or certified at the independent - master's level within three years of their appointment as a social worker
• Most states require two years of post-MSW experience as a prerequisite to taking the licensure/certification exam - and VHA gives social workers one additional year to pass the licensure/certification exam
• In states such as California - Washington - and others where the prerequisites for licensure exceed two years - social workers must become licensed at the independent - master's level within one year of meeting the full state prerequisites for licensure
• A social worker who does not yet have a license that allows independent practice must be supervised by a licensed independent practitioner of the same discipline who is a VA staff member and who has access to the electronic health record
• English Language Proficiency: Candidates must be proficient in spoken and written English to be appointed as authorized by 38 U.S.C. § 7403(f)
• May qualify based on being covered by the Grandfathering Provision as described in the VA Qualification Standard for this occupation (only applicable to current VHA employees who are in this occupation and meet the criteria).Grandfathering Provision: The following is the standard grandfathering policy for all title 38 hybrid qualification standards
• Please carefully review the qualification standard to determine the specific education and/or licensure/certification/registration requirements that apply to this occupation
• Grade Determinations: Social Worker - GS-9: Experience - Education - and Licensure
• None beyond the basic requirements
• Demonstrated Knowledge - Skills - and Abilities
• In addition to the experience above - candidates must demonstrate all of the following KSAs: Ability to work with Veterans and family members from various socioeconomic - cultural - ethnic - educational - and other diversified backgrounds utilizing counseling skills
• 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
• 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
• Ability to establish and maintain effective working relationships and communicate with clients - staff - and representatives of community agencies
• 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: 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
• OR - 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
• Demonstrated Knowledge - Skills - and Abilities: In addition to the experience above - candidates must demonstrate all of the following KSAs: Knowledge of community resources - how to make appropriate referrals to community and other governmental agencies for services - and ability to coordinate services
• 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
• 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
• 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
• 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
• References: VA Handbook 5005/120 - Part II - Appendix G39 - Social Worker Qualification Standard - GS-0185 - Veterans Health Administration - dated September 10 - 2019.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-09 to GS-11
• Physical Requirements: This position requires light lifting - use of fingers - walking - standing - ability to distinguish basic colors - ability to distinguish shades of colors - hearing (Aid permitted) - and operation of a motor vehicle
• See VA Directive and Handbook 5019 - Employee Occupational Health Services.

Duties

• The Homeless Patient Aligned Care Team (H-PACT) is available without appointment or assigned PCP to veterans who identify as homeless or marginally housed with the goal of engaging them health care in the primary care clinic
• The social worker assists the multidisciplinary team in providing care to chronically homeless veterans who are on the streets and in shelters and other temporary housing situations who are eligible for VA care but who have not established ongoing primary care in the VA system
• This constitutes 50% of the social workers time
• Duties for the position include but are not limited to: Works independently with veterans and their families who are experiencing a wide range of complicated medical - psychiatric - emotional - behavioral - and psychosocial problems
• Establishes and maintains effective therapeutic relationships with - and assesses and treats the complicated psychosocial problems of - veterans and their families
• Provides psychosocial care of medically complex patients and offers consultation to colleagues and students on the psychosocial treatment and care coordination of complex patients
• Possesses knowledge of medical and mental health diagnoses - disabilities - and treatment procedures - including acute - chronic - and traumatic illnesses - substance abuse disorders - bereavement - common medications - and general medical terminology
• Participates as a member of the interdisciplinary treatment team to formulate and implement treatment plans identifying the patients' problems - strengths - weaknesses - coping skills and any assistance needed
• Receives referrals from any member of the interdisciplinary team - from veterans and/or their families who call or walk-in for assistance - and from community professionals
• Conducts thorough assessments to determine psychosocial problems that cause distress - often impacting the health condition and creating barriers to care needs of veterans and family members - the underlying causes of the presenting problem - the interpersonal and environmental factors impacting the problem - and its effect on the patient's ability and desire to comply with the treatment recommendations by the multidisciplinary team
• These stressors can include adjustment to the current medical condition - untreated or under-treated mental health or substance abuse conditions - economic instability - legal problems - and inadequate housing and transportation
• Provides consultation and education to veterans and their families regarding community resources - VA benefits and specialty programs - and advance directives
• This requires knowledge of the process for accessing and/or coordinating community-based services - including information and referral for additional services from other VA programs - other government programs - and community programs as well as community agencies that are covered by Medicare - Medi-Cal - and VA pay to ensure veterans receive the services they need with the least amount of financial burden
• Provides interventions to increase access to care - including transportation assistance and advanced directives - economic assistance - finding the appropriate housing for the patient's level of need (affordable independent housing - homeless shelters - group and family care homes - CalVet Homes - assisted living - nursing homes - respite care - hospice care) - and order necessary services to assist with functional decline
• Provides ongoing supportive counseling to assist veterans in dealing with the psychosocial impact of coping with homelessness and understanding barriers to housing - with an ultimate goal of being housed and gainfully employed - when possible
• Helps the veterans and families understand the contributing factors to problems and discusses with them the pros and cons of possible short-term and long-term solutions while encouraging them to make positive and lasting changes to reduce stressors
• Provides wellness/prevention education and stress management - which includes knowledge in Whole Health - facilitates patient/family support groups - and participates in shared medical appointments as appropriate
• Assists veterans and their families with coping and dealing with the loss and grief experiences in disability - terminal illness - and death
• Provides case management interventions for veterans with members of the interdisciplinary team in order to coordinate a collaborative effort to meet the agreed upon goals for veterans' treatment needs
• Work Schedule: Monday - Friday
• 8:00 a.m
• - 4:30 p.m.
• Subject to change to meet the needs of the Agency 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 Financial Disclosure Report: Not required

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About Veterans Affairs, Veterans Health Administration

The Veterans Health Administration (VHA) is the largest integrated health care system in the United States, providing care at 1,321 health care facilities, including 172 VA Medical Centers and 1,138 outpatient sites of care of varying complexity (VHA outpatient clinics) to over 9 million Veterans enrolled in the VA health care program. VHA Medical Centers provide a wide range of services including traditional hospital-based services such as surgery, critical care, mental health, orthopedics, pharmacy, radiology and physical therapy. In addition, most of our medical centers offer additional medical and surgical specialty services including audiology & speech pathology, dermatology, dental, geriatrics, neurology, oncology, podiatry, prosthetics, urology, and vision care. Some medical centers also offer advanced services such as organ transplants and plastic surgery.

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Permanent employment, Temporary work, Work experience placement, Remote job, Relocation package, Monday to Friday,

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