<p>This social worker has responsibility for the provision of social work within assigned segments of the Patient Aligned Care Team (PACT). 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.</p> <p>Major duties include, but are not limited to:</p> <ul> <li>Assessment of psychosocial problems. </li><li>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. </li><li>Case management with members of the outpatient interdisciplinary team. </li><li>Participate in scheduled interdisciplinary team huddles as a method of identifying those Veterans that may "be at risk" and require psychosocial intervention to reduce overall impact of risk. </li><li>Help 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 to reduce stressors. </li><li>Coordinate a collaborative effort to meet the agreed upon goals for a Veteran's treatment needs and include liaison with community professionals regarding needed services for Veterans and/or their families. Services include but are not limited to interventions/referrals to increase access to care, transportation assistance, Advanced Directives, economic assistance, housing assistance for the patient's level of need (affordable independent housing, homeless shelters, group and family care homes, Veterans Homes, assisted living, nursing homes, respite care, hospice care) and necessary services to assist with functional decline. </li><li>Establish and maintain effective therapeutic relationships with Veterans in the Primary Care Clinic and/or their families. </li><li>Complete thorough psychosocial assessments to determine the psychosocial functioning and needs of Veterans and/or their families. </li><li>Facilitate 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. Community placements can involve but are not limited to referrals to contract nursing homes, Community Living Centers, residential care homes, inpatient and outpatient hospice services. </li><li>Utilize telehealth modalities to best meet Veteran needs. </li><li>Provide consultation and education to Veterans and their families regarding community resources, VA benefits and specialty programs, and Advance Directives. </li><li>Serve on committees, work groups, and task forces at the facility as deemed appropriate by the supervisor and Chief of Social Work Services. </li><li>Attend all appropriate staff meetings to include, but not limited to, interdisciplinary treatment team meetings, Social Work team meetings, Social Work supervision meetings, and other committee and workgroups. </li><li>Provide assistance with the orientation and learning of less experienced social workers. </li><li>Other duties as assigned as determined by the direct supervisor, Chief of Social Work Service and/or the Executive Leadership Team of the Battle Creek VA Medical Center. </li></ul> <p>Work Schedule: Monday-Friday, 8:00am-4:30pm. This position will work at both the Battle Creek VA Medical Center and the Lansing VA Clinic. Either location can be the assigned main duty station.</p> <p>Telework: Not eligible.</p> <p>Virtual: This is not a virtual position.</p> <p>Functional Statement #: 93562-A</p>