This position is eligible for the Education Debt Reduction Program (EDRP), a student loan payment reimbursement program. You must meet specific individual eligibility requirements in accordance with VHA policy and submit your EDRP application within four months of appointment. Approval, award amount (up to $200,000) and eligibility period (one to five years) are determined by the VHA Education Loan Repayment Services program office after complete review of the EDRP application. Learn more Work Schedule: Monday - Friday; 7:30am - 4:00pm Financial Disclosure Report: Not required Telework: Not eligible Relocation/Recruitment Incentives: Authorized. EDRP Authorized: Contact V21CCOEEDRP@va.gov, the EDRP Coordinator for questions/assistance Financial Disclosure Report: Not required The Social Worker serves as a core member of the interdisciplinary Hospital in Home (HIH) treatment team which is a specialized program under the administration of the Medicine Service. The Senior Social Worker must work independently without access to social work supervision to provide expert level psychosocial interventions and services to veterans with complex medical, social and behavioral conditions in which routine clinic-based care is not effective. Patients served in the HIH Program are those who require intensive monitoring and medication adjustment due to exacerbation of CHF, COPD, diabetes or other medical issues that may require hospital level of care to be provided in the comfort of their own home. The Veteran is managed in the home by an interdisciplinary team as opposed to being admitted to hospital. Incumbent utilizes advanced practice skills, knowledge and judgment in developing and measuring effectiveness of social work practice and services and utilizing outcome evaluations to improve treatment services. Coordination of specialized psychosocial services and programs are also provided. The Incumbent will also provide social work assessment and interventions to veterans hospitalized on acute care units at the Sierra Nevada VA Hospital. Special attention will be provided to high risk and vulnerable populations who have frequent Emergency Department visits, hospitalizations and/or are at increased risk for readmission due to social or medical circumstances. The Social Worker must have a high level of skill and expertise to establish and maintain effective therapeutic relationships with highly complex Veterans and/or their families. The incumbent must work independently with Veterans and their families who are experiencing a wide range of complicated medical, psychiatric, emotional, behavioral, financial, legal and psychosocial problems. Interventions are primarily in the veteran's home and demand a high amount of drive time. Multiple visits per week may be made to the Veteran as needed. The Social Worker practices at the advance level and has specialized knowledge of practice typically related to terminal, acute or chronically ill patients. Incumbent is required to have a minimum of two years specialized experience working with this population, and licensed or holds certification in a state at the advanced practice level. Duties of the position include, but are not limited to: Independently provide 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. Complete all applicable clinical reminders. The incumbent will attend weekly interdisciplinary care planning meetings. Address the unique needs of veterans with acute medical exacerbations. Possess a working knowledge and experience in use of medical and mental health diagnoses, disabilities, and treatment procedures. Collaborate with other service providers in reassessing the veteran's needs for non-institutional, institutional services/programs and entitlements. Responsible for educating the veteran and/or caregiver of the available services and assisting them in establishing the appropriate referrals based on the veteran's preference or that of his surrogate decision-maker. Responsible for developing a resource file of VA and community social service programs and will refer the veteran to needed services. The incumbent is able to coordinate community-based services from other VA programs, government programs and community agency programs. Facilitates and prioritizes referrals based upon veterans needs and eligibility. Be available to assist the medical and surgical inpatient and outpatient health care team via consultation with or without direct patient contact about indications for social work referral; possible psychosocial aspects and intervention methods for coping with progressive, debilitating illness; psychosocial stressors and interventions related to non-compliance due to inadequate psychosocial support; health care and future placement planning; interventions related to capacity and guardianship needs; caregiver stress and support; and financial benefits. Act as an advocate when it serves the best interest of the veteran/family. Educate and encourage the veteran/family to advocate on their own behalf, thus fostering a sense of independence and empowerment. Provide the veterans and their caregivers with ongoing supportive counseling. Other duties as assigned by management.
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.