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. Clinical Functions: Responsibilities include the assessment of psychosocial problems that cause distress, often impacting the health condition and creating barriers to care. The incumbent must complete thorough assessments to determine the underlying causes of the presenting problem, the interpersonal and environmental factors impacting the problem, and its affect on the patient's ability and desire to comply with the treatment recommendations by the multidisciplinary team. Helps the patient and family to understand the contributing factors to the problem(s), will discuss with them the pros and cons of possible short-term and long-term solutions, encouraging them to make positive and lasting changes and will coordinate with VA staff and community agencies to assist in problem solving as needed. - independently complete thorough psychosocial assessments to determine the psychosocial functioning and needs of Veterans and/or their families.- actively participates as a member of the interdisciplinary treatment team. - facilitates action for community placements through collaboration with Veterans and their families as well as interdisciplinary treatment team members. - able to use and teach Veterans in the effective use of the My HealtheVet (MHV) system. Must possess 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. Administrative functions: - Serves on committees, work groups, and task forces at the facility as deemed appropriate by the supervisor and Chief of Social Work Services. - keeps their supervisor apprised of problems and recommended solutions to problems encountered in the incumbent's area of responsibility. - provide 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. - maintain 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. - is willing to modify tour of duty as necessary to accommodate the needs of Veteran patients. Work Schedule: Monday - Friday 8:00am to 4:30pm 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.