<p>This position is located at the Cincinnati VA Medical Center, in support of the Social Work service. The employee is a core member of the interdisciplinary Home- Based Primary Care (HBPC) Treatment Team which is a specialized program under the administration of Primary Care. The Senior Social Worker provides expert level psychosocial interventions and case management services to Veterans with complex medical, social and behavioral conditions in which routine clinic-based care is not effective.</p> <p>The Cincinnati VA Medical Center (CVAMC) is a two-division campus located in Cincinnati, OH and Fort Thomas, KY serving 15 counties in Southwest OH, Northern Kentucky, and Southeast Indiana with 6 Community Based Outpatient Clinics located in Bellevue, KY; Florence, KY; Lawrenceburg, IN; Hamilton, OH; Clermont County, OH, and Georgetown, OH. The CVAMC also supports two off main campus locations in the Cincinnati area via an Eye Center and Mental Health Outreach Community Division.</p> <p>Duties include but are not limited to:</p> <ul> <li>Provides a comprehensive psychosocial assessment and integrates it into an overall plan of care in collaboration with the interdisciplinary treatment team, the Veteran, family members and significant others, whenever possible. </li><li>Designs systems changes based on observations, data and experience. </li><li>Facilitates and prioritizes referrals based upon Veterans' needs and eligibility. </li><li>Identifies and prioritizes high-risk patients and provides case management services. </li><li>Provides consultation services to other staff regarding the psychosocial needs of Veterans and the impact of psychosocial problems on health care and adherence to treatment plan. </li><li>Possesses the advanced practice skills to independently make a psychosocial diagnosis and offer psychosocial interventions, and then measures outcomes to interventions. </li><li>Participates and can lead weekly interdisciplinary care planning meetings when asked by the HBPC program director. </li><li>Coordinates community-based services, including information and referral for additional services from other VA programs, other government programs and community agency programs. </li><li>Facilitates and prioritizes referrals based upon Veterans needs and eligibility. </li><li>Provides education related to VA and community resources, entitlements, Advance Directives/Living Will and will refer Veterans/families to the appropriate interdisciplinary team member for identified health education needs. </li><li>Establishes and maintains effective therapeutic relationships with Veterans and their families. </li><li>Enters all Veteran/family contacts in the electronic record using appropriate formats and templates. </li><li>Establishes and maintains positive working relationships with employees, volunteers, consumers and stakeholders within the VA and outside community agencies. </li><li>Collaborates in the performance improvement processes and support performance measures as required by the VA for their specialized population and/or program. </li><li>Performs all other duties as assigned. </li></ul> <p>Work Schedule: Monday through Friday; 7:30am to 4:00pm</p> <p>Compressed/Flexible:Not Available</p> <p>Telework: Not Available</p> <p>Virtual: This is not a virtual position.</p> <p>Functional Statement #: 91268-0</p> <p>Relocation/Recruitment Incentives: Not Authorized</p>