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Senior Social Worker
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The Hospice and Palliative Care Senior Social Worker is an independent professional specialized social worker assigned to Geriatrics and Extended Care Service and aligned with the Palliative Care Consult team at the Sacramento VA Medical Center on inpatient acute care and intensive care units, in the Emergency department (ED), in the outpatient palliative care clinics, and on the Behavioral Health Intensive Care Unit (BHICU).
Duties
Work Schedule: Full Time; Monday - Friday 8:00 a.m. - 4:30 p.m.; Subject to change to meet the needs of the Agency
Telework: Telework authorized per Agency policy; this is not a remote or virtual position.
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
The Senior Social Worker performs specialized treatment, case management, and collaboration of care with the medical and community providers involved in providing care to Veterans. The incumbent serves on an interdisciplinary team and must use a high level of skill in assessing and treating the complicated psychosocial problems of veterans with complex physical and mental symptoms resulting from serious and life-limiting illnesses.
The incumbent's duties include but are not limited to completion of thorough biopsychosocial assessments, provision of case-management for patients with ongoing palliative care needs, referral and coordination of services and resources, supportive counseling for patients and their families, conducting goals of-care discussions, coordinating hospice referrals and placement into skilled nursing facilities or residential care facilities, acting as liaison with community hospice partners, providing counseling and assistance with advance directives, and palliative care program development.
Duties for the position may include but are not limited to:
- Incorporation of complex multiple causation in differential diagnosis and treatment in Veteran patients, including making psychosocial and psychiatric diagnoses within approved clinical privileges or scope of practice.
- Provision of individual, group and family counseling or psychotherapy and advanced level case management interventions used in the treatment of veterans with complex medical and psychiatric disorders in either an inpatient or outpatient basis.
- Participation as an active member of the inpatient and outpatient Palliative Care interdisciplinary treatment teams to provide social work interventions to Veterans and/or their families to meet treatment goals within the context of their goals of care.
- Development and implementation of a bereavement support program, in conjunction with the Chaplain service, for the families of veterans who die at the Sacramento VA Medical Center.
- Participation in active case finding for the inpatient and outpatient Palliative Care services.
- Provision of training, consultation and education to other treatment teams, staff members, and the community at large regarding hospice and palliative services, and role modeling effective social work practice skills.
- Helping the Veteran cope with end-of-life or complex chronic illness diagnoses and assessment of treatment options and when appropriate, making referrals based on the Veteran's preference or that of the surrogate decision-maker.
- Supporting end-of-life planning/care preferences through assistance with advance directives and completion of goals of care conversations.
- Making rapid assessments and developing management plans in periods of crisis for Veterans and their families.
- Providing education and referrals where appropriate related to the patient's VA, Social Security, disability benefits, and community resources.
- Referral to and coordination of hospice care services including facilitation of Community Care referrals. Having knowledge of and making referrals to a wide range of community services, including Medical Foster Homes, group and family care homes, Assisted Living Facilities, Adult Day Health Care programs, Contract Nursing Homes, Community Living Centers, residential care homes, and inpatient and outpatient hospice services.
- Participation in specialty hospital committee meetings and initiatives.
- Acting as the representative and liaison of Hospice and Palliative Care from the facility to the greater community and acting as an advocate to serve the best interests of the Veteran, family, and caregiver.
- Other duties as assigned.
