Social Worker-Patient Aligned Care Team
1 month ago
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 in this Veteran-centric approach often functions as a care coordinator with a panel of veterans to ensure that health care meets the needs, as defined by the Veteran.
Duties
- High level of skill and expertise to establish and maintain effective therapeutic relationships with Veterans in the Primary Care Clinic and/or their families.
- Able to independently work with Veterans and their families who are experiencing a wide range of complicated medical, psychiatric, emotional, behavioral, financial, legal and psychosocial problems. Effective social work in the Patient Centered Medical Home context often occurs over a series of several visits and may involve the need of the social worker to visit the veteran in their home.
- Independently completes thorough psychosocial assessments to determine the psychosocial functioning and needs of Veterans and/or their families. The incumbent must be able to utilize this assessment in facilitating the Veteran's maximum use of treatment for attainment of the highest level of independence that is possible and practicable.
- Actively participates as a member of the interdisciplinary treatment team and actively participate through collaboration with Veterans and family as well as interdisciplinary treatment team members in the development and implementation of treatment goals and interventions.
- Possess a working knowledge and experience in use of medical and mental health diagnoses, disabilities, and treatment procedures, including acute, chronic and traumatic illnesses, substance abuse disorders, common medications and their effects/side effects, and medical terminology.
- Facilitates action for community placements through collaboration with Veterans and their families as well as interdisciplinary treatment team members to ensure that appropriate community placements are completed in a timely manner.
- Serves as a liaison between Veterans and/or their families and VA and community resources in order to ensure thorough delivery of services.
- Ability to independently implement treatment modalities, provide educational classes, and/or supportive groups for Veterans and families, including shared medical appointments. The social worker must be able to use and teach Veterans in the effective use of the My HealtheVet system.
- Possesses skill in using computer systems, especially the internet for Veterans who choose this modality to communicate with the team.
- 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. The incumbent will be able to appropriately utilize principles of human growth and development over the life span and will be able to assist Veterans in coping with the loss and grief experiences from disability and terminal illness.
- Demonstrates the ability to communicate effectively, both orally and in writing with people from varied backgrounds.
- Responsible for supporting the mission, policies, and procedures of the Department of Veterans Affairs, the Veterans Health Administration, Veterans Integrated Service Network (VISN) 19, and VA Eastern Colorado Healthcare System.
- Willing to serve on committees, work groups, and task forces at the facility as deemed appropriate by the supervisor and Chief of Social Work Services.
- Keeps 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 graduate level social work students.
- 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.
- Willing to modify tour of duty as necessary to accommodate the needs of Veteran patients.
Compressed/Flexible: Available
Telework: Not Available
Virtual: This is not a virtual position.
Functional Statement #: 53710-O & 53711-O
Relocation/Recruitment Incentives: Not Authorized
Permanent Change of Station (PCS): Not Authorized
Financial Disclosure Report: Not required
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Aurora, Colorado, United States Department Of Veterans Affairs Full timeSummary The Licensed Practical Nurses (LPN) practice is modeled on the standards established within the VHA model for Patient Aligned Care Teams. The LPN performs a variety of supportive, nursing, and medical tasks necessary to the care of patients during diagnostic and therapeutic visits to the Rocky Mountain VA Medical Center Outpatient Clinic....
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Aurora, Colorado, United States Department Of Veterans Affairs Full timeSummary The Licensed Practical Nurses (LPN) practice is modeled on the standards established within the VHA model for Patient Aligned Care Teams. The LPN performs a variety of supportive, nursing, and medical tasks necessary to the care of patients during diagnostic and therapeutic visits to the Rocky Mountain VA Medical Center Outpatient Clinic....
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