Social Worker (Geriatric Care Coordinator)

Full Job Description

This position is located in Geriatric and Extended Care Service of the Fayetteville NC VA Coastal Healthcare System.

The duties and responsibilities are carried throughout the Healthcare System including all clinical and other patient care areas involved with the services.

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: 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). 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. 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/. GS-12: Licensure/Certification.

Individuals assigned as social worker program coordinator must be licensed or certified at the advanced practice level, and must be able to provide supervision for licensure. Experience and Education.

One year of experience equivalent to the GS-11 grade level. Experience must demonstrate possession of advanced practice skills and judgment, demonstrating progressively more professional competency.

Candidate may have certification or other post-master's degree training from a nationally recognized professional organization or university that includes a defined curriculum/course of study and internship, or equivalent supervised professional experience.

In addition to the experience above, the candidate must demonstrate all of the following: Knowledge of program coordination and administration which includes consultation, negotiation, and monitoring.

Knowledge and ability to write policies, procedures, and/or practice guidelines for the program. Ability to supervise multidisciplinary staff assigned to the program.

Skill in organizing work, setting priorities, meeting multiple deadlines, and evaluating assigned program area(s). Ability to provide training, orientation, and guidance within clinical practice.

Major Duties:

Duties and responsibilities include but are not limited to: Administers information and analytical systems to evaluate and enhance the quality of service provided to Veterans in the Rede?ning Elder Care in America Project (RECAP).

Develops and implements information systems to track service activities including visits, referrals, inpatient days, patient demographics, equipment utilization and patient satisfaction.

Develops implements and evaluates clinical guidelines and protocols to establish appropriate utilization of services and referrals to Non-Institutional Care Programs.

Contacts and establishes a continuing relationship with the Veteran, evaluating progress towards goals and adjusting the treatment plan as appropriate.

Meets with Veterans to assess accomplishments and re-establish goals as needed. Makes recommendations for care and changes to interdisciplinary treatment plan.

Interviews Veterans and their family members/signi?cant others to obtain facts about the Veteran's situation, presenting problems and causes, and the impact of such problems on the Veteran's functioning and health as part of a comprehensive psychosocial assessment.

The assessment focuses on the patient in the context of family and community by integrating an assessment of living conditions, individual and family dynamics, and cultural background into the patient's plan of care.

Interprets and explains VA's treatment, services, and bene?t programs. Reviews all data, subjective and objective, and makes a clinical assessment, identifying needs and strengths.

E?ectively uses professional skill, objectivity and insight. Uses advanced clinical training, insight and experience to interpret data and to identify viable treatment options.

Assesses high risk factors, acuity and need for services.

Has the ability to serve Veterans who have serious, frequent medical crises, lack of adequate family or community support network, have limited ?nancial resources, are poor at self-monitoring, frequently fail to comply with instructions and treatment, have signi?cant de?cits in coping skills and require continuing professional psychological support.

Has the ability to serve Veterans su?ering from life-altering traumatic physical disabilities. Clients include those at high risk of continuous or repeated institutionalization.

Independently evaluates the client's situation, including the Veteran's reaction to it and ability to deal with it, and arrives at a reasoned conclusion.

Based on the psychosocial assessment, uses professional judgment and advanced practice skills to make a psychosocial diagnosis.

Assesses at-risk factors and develops a preliminary disposition plan, involving the Veteran and family or signi?cant others.

Performs insightful assessment of serious and complicated cases involving psychiatric illness, catastrophic medical conditions, dementia and other high-risk diagnoses.

Makes independent professional decisions and recommendations for agency action. Cases involved hard-to-reach personalities and the problems are di?cult to deal with.

Consequences to the Veteran may be serious and the results are often unpredictable.

On an inpatient/outpatient basis, ?nds a suitable means of treatment to help Veterans and/or signi?cant others cope with stressful situations.

Treatment is aimed at helping Veterans ?nd practical solutions to problems.

Develops psychosocial treatment plans in coordination with interdisciplinary team members, including goals for psychosocial treatment.

Using known available resources and the initial assessment of the Veteran's likelihood to accept di?ering types of assistance, makes initial and ongoing decisions regarding use of VA and non-VA services and referrals.

Arrives at a reasoned conclusion as to the preferred course of action. Provides independent consultation and makes recommendations to interdisciplinary team on course of treatment.

Must have knowledge of the vast array of VA, federal, state and local community agencies and resources. Incumbent must also have knowledge of terminal illness and end of life planning processes.

Independently implements the appropriate action, even in instances where actions can have serious impact on the life of the Veteran.

This might include long-term institutional or nursing home care or separation from family members.

These decisions are based on the social worker's advanced practice skills, professional judgment and expertise regarding the Veteran's ability to care for himself/herself, the family support system, the Veteran's health care needs and possible consequences.

Performs other directly related duties as assigned. Work Schedule: Monday - Friday, 8am - 4:30pm Telework: Ad Hoc, as determined by the agency policy