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The Patient Aligned Care Team 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 with a panel of Veterans to ensure that health care meets the needs, as defined by the Veteran. To qualify for this position, applicants must meet all requirements within 30 days of the closing date of this announcement. Basic Requirements: Citizenship. Be a citizen of the United States. (Non-citizens may be appointed when it is not possible to recruit qualified citizens in accordance with chapter 3, section A, paragraph 3g this part). English Language Proficiency. Candidates must be proficient in spoken and written English to be appointed as authorized by 38 U.S.C. § 7403(f). 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 masters 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/. Exception. VHA may waive the licensure or certification requirement for persons who are otherwise qualified, pending completion of state prerequisites for licensure/certification examinations. This exception only applies at the GS-9 grade level. For the GS-11 grade level and above, the candidate must be licensed or certified. At the time of appointment, the supervisor, chief social work or social work executive will provide the unlicensed/uncertified social worker with the written requirements for licensure or certification, including the time by which the license or certification must be obtained and the consequences for not becoming licensed or certified by the deadline. Grade Determinations: In addition to the basic requirements for employment, the following criteria must be met when determining the grade of candidates. Social Worker, GS-11 (1) 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 please refer to paragraph 3c. OR (2) 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. (3) Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, candidates must demonstrate all of the following KSAs: (a) Knowledge of community resources, how to make appropriate referrals to community and other governmental agencies for services, and ability to coordinate services. (b) 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. (c) 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. (d) 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. (e) 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. Preferred Experience: Working with veterans, case management/discharge planning experience. At least 2 years Social Work and/or Home care experience preferred References: VA HANDBOOK 5005/120 September 10, 2019 PART II APPENDIX G39 The full performance level of this vacancy is GS-11. Physical Requirements: Use of fingers; both hands required; specific visual requirement(see computer screen); hearing (aid permitted) Environmental Factors: Working closely with others; working alone ["Recruitment Incentive Authorized Clinical Functions: Must have a high level of skill and expertise to establish and maintain effective therapeutic relationships with Veterans in the Primary Care Clinic and/or their families. Able to independently work with Veterans and their families who are experiencing a wide range of complicated medical, psychiatric, emotional, behavioral, financial, legal and psychosocial problems. Effective social work in the Patient Aligned Care Team context often occurs over a series of several visits and may involve the need of the social worker to visit the Veteran in their home. Knowledge of the PACT team approach and the role of each health and allied health care team members as well as an understanding of the role of the social worker in the PACT model. Independently complete thorough psychosocial assessments to determine the psychosocial functioning and needs of Veterans and/or their families. Assess functional acuity of the patient and provide appropriate interventions. Utilize this assessment in facilitating the Veteran's maximum use of treatment for attainment of the highest level of independence that is possible and practicable. Participate as a member of the interdisciplinary treatment team and actively participate through collaboration with Veterans and family as well as interdisciplinary treatment team members in the development and implementation of treatment goals and interventions. Working knowledge and experience in use of medical and mental health diagnoses, disabilities, and treatment procedures, including acute, chronic and traumatic illnesses, substance abuse disorders, common medications and their effects/side effects, and medical terminology. 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 group and family care homes, assisted living facilities, adult day health care programs, contract nursing homes, Community Living Centers, residential care homes, inpatient and outpatient hospice services. Understanding of caregiver stressors, ability to conduct caregiver assessment and provide appropriate caregiver specific interventions. Liaison between Veterans and/or their families and VA and community resources in order to ensure thorough delivery of services. Independently implement treatment modalities and evidence-based practices as well as provide educational classes, and/or supportive groups for Veterans and families, including shared medical appointments. Use and teach Veterans in the effective use of the My HealtheVet system. Must possess skill in using computer systems, especially the internet for Veterans who choose this modality to communicate with the team. Consultation and education to Veterans and their families regarding community resources, VA benefits and specialty programs, and Advance Directives. Knowledge of the process for accessing and/or coordinating community-based services, including information and referral for additional services from other VA programs, other government programs, and community programs. Provide consultation to other treatment team and staff members regarding psychosocial needs of Veterans and/or their families and the impact of the identified psychosocial problems on the Veteran's health care planning and compliance with treatment. Knowledge of Veteran's benefits and services, community resources, and process for making appropriate referrals to community and other governmental programs or agencies. Provide case management services to Veterans and their families throughout the continuum of care. Appropriately utilize principles of human growth and development over the life span and will be able to assist Veterans in coping with the loss and grief experiences from disability and terminal illness. Knowledge of the signs and symptoms of abuse, neglect and exploitation. Communicate effectively, both orally and in writing with people from varied backgrounds. Work Schedule: Mon-Fri 8-4:30 Telework: Not Available Virtual: This is not a virtual position. Functional Statement #: 00000000 Relocation/Recruitment Incentives: Authorized Permanent Change of Station (PCS): Not Authorized Financial Disclosure Report: Not required"]

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