The incumbent is responsible for the monitoring of, and discharge planning for, Veterans assigned to the PACT Team while Veterans are hospitalized in any number of local medical facilities. The incumbent must complete thorough assessments to determine the presenting problem to determine in-home factors impacting the problem and to determine obstacles to treatment and/or follow through with recommended treatments. Duties include but are not limited to: a) Screening/Assessment: Completes assessments Veterans in collaboration with the interdisciplinary treatment team, the Veteran, family members and significant others. Identifies needs and formulate a plan to meet those needs. Possess skills to determine needs for all adult patients (including geriatric patients) related to their physical li
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