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The Social Work - Home Based Primary Care position is located at VA Western New York Healthcare System, located at the Batavia, with flexibility to cover other program locations as needed. This is a complexity level 1B facility. The incumbent is assigned to Geriatric and Extended Care (GEC) Line and works in collaboration with multiple teams including: Geriatrics and Extended Care (GEC), Behavioral Health Care Line (BVAC), Medicine Teams and Patient Aligned Care Teams (PACT). Applicants pending the completion of educational or certification/licensure requirements may be referred and tentatively selected but may not be hired until all requirements are met. Basic Requirements: Social Worker Citizenship: US Citizen 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 Master 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/. May qualify based on being covered by the Grandfathering Provision as described in the VA Qualification Standard for this occupation (only applicable to current VHA employees who are in this occupation and meet the criteria). Grade Determinations: Creditable Experience: The candidate must have knowledge of current professional social work practices. To be creditable, the experience must have required the use of knowledge, skills, abilities, and other characteristics associated with current professional social work practice. The experience or education must be post-Master of Social Work (MSW) degree. Experience and education satisfying this requirement must be active professional practice, which is paid/non-paid employment as a professional social worker, as defined by the appropriate state licensing board. Social Worker-Home Based Primary Care GS-11 Experience and Licensure: Appointment to the GS-11 grade level requires completion of a minimum of one year of post-MSW experience equivalent to the GS-9 grade level in the field of health care or other social work-related settings, (VA or non-VA experience) and licensure or certification in a state at the independent practice level. NOTE: For appointment licensure or certification at this level must be Unrestricted, at the Independent Practice Level, with the ability to work independently. OR Education: In addition to meeting basic requirements, a doctoral degree in social work from a school of social work may be substituted for the required one year of professional social work experience in a clinical setting. Demonstrated Knowledge, Skills, and Abilities: In addition to the experience above, candidates must demonstrate all of the following KSAs: Knowledge of community resources, how to make appropriate referrals to community and other governmental agencies for services, and ability to coordinate services. Skill in independently conducting psychosocial assessments and treatment interventions to a wide variety of individuals from various socio-economic, cultural, ethnic, educational and other diversified backgrounds. Knowledge of medical and mental health diagnoses, disabilities and treatment procedures (i.e. acute, chronic and traumatic illnesses/injuries, common medications and their effects/side effects, and medical terminology) to formulate a treatment plan. Skill in independently implementing different treatment modalities in working with individuals, families, and groups who are experiencing a variety of psychiatric, medical, and social problems to achieve treatment goals. Ability to provide consultation services to new social workers, social work graduate students, and other staff about the psychosocial needs of patients and the impact of psychosocial problems on health care and compliance with treatment. Assignments: This is the full performance level. Social workers at this level are licensed or certified to independently practice social work. Duties include but are not limited to assessing and documenting identified behaviors or symptoms of abuse, neglect, exploitation and/or intimate partner violence; use of clinical social work skills and knowledge to maintain Veteran privacy and confidentiality per policies, handbooks or directives; and acts as an advocate with appropriate VA and community service providers and agencies when it serves the best interest of the Veteran and family members/caregiver. Incumbent independently assesses the psychosocial functioning and needs of Veterans and their family members, identifying the Veteran's strengths, weaknesses, coping skills, and psychosocial acuity. In collaboration with the Veteran, family/caregiver, and interdisciplinary treatment team, the social worker facilitates the delivery of health care services. The social worker identifies family/caregiver stressors, conducts assessment and provides specific interventions. The incumbent provides case management and care coordination to facilitate appropriate delivery of health care services, incorporates complex multiple causation in differential diagnosis and treatment of Veterans, including making psychosocial and psychiatric diagnoses within approved clinical privileges or scope of practice. The social worker links the Veteran with services, resources, and opportunities, in order to maximize the Veteran's independence, health, and well-being. The social worker conducts timely assessment of at-risk Veterans in crisis to identify immediate needs, evaluate risk, and initiate safety plan as appropriate. The social worker provides interventions independently with Veterans and their families/caregivers who are experiencing a wide range of complicated medical, behavioral health, financial, legal, and psychosocial problems. They provide a range of interventions and treatment modalities which may include individual, group, and/or family counseling or psychotherapy. They independently formulate and implement a treatment plan including measurable, achievable goals identifying the Veterans' needs, strengths, weaknesses, coping skills, and psychosocial acuity. Social workers serve on committees, work groups, and task forces at the facility and VISN level or in the community. They provide subject matter consultation to colleagues and students on the psychosocial treatment of Veterans offering professional opinions based on experience, expertise and role modeling effective social work practice skills. The social worker establishes and maintains ongoing education programs for Veterans, community agencies, students, and staff, to facilitate understanding of social work interventions specific to the Veteran/Military population. Preferred Experience: Homecare and geriatric experience is preferred. The position requires driving to and from home visits. References: VA HANDBOOK 5005/120 PART II APPENDIX G39 The full performance level of this vacancy is GS-11. The actual grade at which an applicant may be selected for this vacancy is in the range of GS-9 to GS-11. Physical Requirements: See VA Directive and Handbook 5019, Employee Occupational Health Services ["VA Careers - Social Work: https://youtube.com/embed/enRhz_ua_UU Major Duties: GS-11 Social Worker Home Based Primary Care: This position requires you to working alone and without close supervision. Clinical Functions: Provides a full range of social work services within commonly accepted standards of social work practice, which includes casework, individual, family and group counseling, discharge planning, case management and other services as appropriate, implementing treatment modalities appropriately. Direct services provided including: social work triage, identifying patient discharge disposition, making referrals for post hospital needs such as home health aide, skilled nursing, in-home rehab services, transportation, adult day health care, behavioral health programs, etc.; providing health care proxy/living will education and completion; economic assistance or financial aid services and strategies to increase income (employment, vocational rehabilitation, VA benefits, disability); determining patient disposition which may involve placement to the least restrictive environment i.e. retirement facility/supportive living, assisted living, nursing home, or homeless shelter, group home, or a return to the prior to admission living situation. Complete comprehensive evaluation and or assessment to determine the needs of patients and family members especially identifying possible environmental impediments that could complicate overall care. The social worker in concert with the patient, family and team, while considering socioeconomic, cultural, ethnic, educational and diversified backgrounds, will determine and execute interventions to overcome any predetermined barriers. Provides crisis management when indicated and makes appropriate referrals to VA programs or community resources in compliance with established VA policy and procedures. Advocate on behalf of patient to ensure services are obtained in a timely manner. Act as a liaison between patient/family and medical team in communicating concerns or issues of importance. Possessing the necessary knowledge of medical and mental health diagnoses and treatments to provide individual and family counseling to help lessen the distress associated with acute and chronic illness issues. Provide consultation/education to veterans and families on community resources, advance directives and VA benefits. Provide consultation/education to other team/staff members, medical residents on social work practice and VA policy and procedure. Provide case management and assessment of the psychosocial functioning and needs of to veterans and families, as needed, throughout the continuum of inpatient care and make a warm handoff to the outpatient social worker. Provides home visits to veterans in a 60-mile radius of the medical center. Communicate effectively in oral and in writing, using the appropriate medical terminology, as needed. Administrative Functions: Is responsible for supporting the mission, policies, and procedures of the Department of Veterans Affairs, the Veterans Health Administration (VHA), the appropriate Veterans Integrated Service Network (VISN), and the facility. Serves on committees, work groups, and task forces at the facility as deemed appropriate by the supervisor. Is mindful of keeping their supervisor apprised of problems and recommended solutions to problems encountered in the incumbent's area of responsibility. Is 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 orientation and learning. Demonstrate knowledge and skill in the use of software applications for drafting documents. Demonstrates knowledge and skill in data management/encounter completion/CPT procedure coding. Documents social work case management activities in patient's medical record in timely and thorough fashion, completing encounters accurately reflecting all services provided. Social Work Consults are answered within designated time frame and response/treatment is congruent with the provider's request and patient's needs. Work Schedule: Monday to Friday 8:00AM to 4:30PM\nCompressed/Flexible: Available\nTelework: Available\nVirtual: This is not a virtual position.\nFunctional Statement #:23948-F\nRelocation/Recruitment Incentives: Not Authorized\nPermanent Change of Station (PCS): Not Authorized\nPCS Appraised Value Offer (AVO): Not Authorized\nFinancial Disclosure Report: Not required"]