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The incumbent provides veterans in the Home Based-Primary Care (HBPC) Program with high quality case management, clinical treatment, advocacy, and to coordinate linkage with appropriate VA and community service providers / agencies as needed by the client. 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: United States Citizenship: Non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy. 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/. Once licensed or certified, social workers must maintain a full, valid, and unrestricted independent license or certification to remain qualified for employment. Loss of licensure or certification will result in removal from the GS-0185 social worker series and may result in termination of employment. English Language Proficiency: Candidates must be proficient in spoken and written English to be appointed as authorized by 38 U.S.C. § 7403(f). 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). Grade Determinations: GS -12- Social Worker - Senior Social Worker Experience and Education: One must have at least two years of experience post advanced practice clinical licensure and should be in a specialized area of social work practice of which, one year must be equivalent to the GS-11 grade level. Senior social workers have experience that demonstrates possession of advanced practice skills and judgment. Senior social workers are experts in their specialized area of practice. Senior social workers may have certification or other post-masters training from a nationally recognized professional organization or university that includes a defined curriculum/course of study and internship or equivalent supervised professional experience in a specialty. Licensure/Certification: Individuals assigned as social worker program coordinator must be licensed or certified at the advanced practice level, and must be able to provide supervision for licensure. Demonstrated Knowledge, Skills, and Abilities: In addition to the experience above, the candidate must demonstrate all of the following KSAs: (a) Skill in a range of specialized interventions and treatment modalities used in specialty treatment programs or with special patient populations. This includes individual, group, and/or family counseling or psychotherapy and advanced level psychosocial and/or case management. (b) Ability to incorporate complex multiple causation in differential diagnosis and treatment within approved clinical privileges or scope of practice. (c) Knowledge in developing and implementing methods for measuring effectiveness of social work practice and services in the specialty area, utilizing outcome evaluations to improve treatment services and to design system changes. (d) Ability to provide specialized consultation to colleagues and students on the psychosocial treatment of patients in the service delivery area, as well as role modeling effective social work practice skills. (e) Ability to expand clinical knowledge in the social work profession, and to write policies, procedures, and/or practice guidelines pertaining to the service delivery area. Assignments. For all assignments above the full performance level, the higher-level duties must consist of significant scope, complexity (difficulty), and variety and be performed by the incumbent at least 25% of the time. Senior social workers are licensed or certified to independently practice social work at an advanced level. Senior social workers typically practice in a major program area such as but not limited to: Polytrauma Rehabilitation Center or Polytrauma Network Site; a Spinal Cord Injury Rehabilitation Center, or a national VHA referral center, such as a national Center for Post-Traumatic Stress Disorder or a national Transplant Center, or other program areas of equivalent scope and complexity. The senior social worker may be assigned administrative responsibility for clinical program development and is accountable for clinical program effectiveness and modification of service patterns. Assignments include clinical settings where they have limited access to onsite supervision such as CBOCs or satellite outpatient clinics. The senior social worker collaborates with the other members of the treatment team in the provision of comprehensive health care services to Veterans, ensures equity of access, service, and benefits to this population, ensures the care provided is of the highest quality. The senior social worker provides leadership, direction, orientation, coaching, in-service training, staff development, and continuing education programs for assigned social work staff. They serve on committees, work groups, and task forces at the facility, VISN and national level, or in the community as deemed appropriate by the supervisor, Social Work Executive or Chief of Social Work Services. This assignment is to be relatively few in number based on the size of the facility/service and applying sound position management. This assignment must represent substantial additional responsibility over and above that required at the full performance grade level and cannot be used as the full performance level of this occupation. Preferred Experience: At least one year of experience working within the VA system, preferably on an outpatient setting or primary care setting. At least one year of experience working with an interdisciplinary team, preferably on an outpatient setting or primary care setting. Demonstration of working knowledge in the field of geriatrics, preferable in an in-home environment. Demonstration of working knowledge of community resources specific to the medically compromised and geriatric community. Experience or knowledge of capacity assessments for geriatric patients. References: VA Handbook 5005/120 Part II Appendix G39 Social Worker Qualification Standard, September 10, 2019 The full performance level of this vacancy is GS-12. Physical Requirements: Light lifting and carrying, under 15 pounds, reaching above shoulder, use of fingers, both hands required, walking and standing up to four hours, repeated bending (one hour), climbing, legs only (one hour), climbing, use of legs and arms, both legs required, ability for rapid mental and muscular coordination simultaneously, near vision correctable 13" to 16" to Jaeger 1 to 4, far vision correctable in one eye to 20/20 and to 20/40 in the other, both eyes required, depth perception, ability to distinguish basic colors, hearing aid permitted, and hearing without aid. ["VA Careers - Social Work: https://youtube.com/embed/enRhz_ua_UU Screening/Assessment-The social worker will develop an assessment of the veteran in collaboration with the interdisciplinary treatment team, the veteran, family members and significant others, whenever possible. The goal of the assessment is to highlight the veteran's strengths, limitations, and internal/external supports and service needs in order to optimize the veteran's functional status and safely maintain the veteran in his/her home. The assessment will include a home visit. It is the responsibility of the social worker, working within the interdisciplinary treatment team to develop a treatment plan with the veteran based on this assessment. Treatment Planning/Goal Setting - The social worker is responsible for developing the treatment plan and setting achievable treatment goals with the veteran/family in collaboration with the HBPC interdisciplinary treatment team members. The social worker will include psychosocial problems onto the interdisciplinary treatment plan. Will attend weekly interdisciplinary care planning meetings. Social workers will address the unique needs of homebound, frail, disabling/chronic and/or dying veteran. Referral to service providers - Throughout the course of treatment the social worker is the subject matter expert on VA and/or community resources. The social worker will collaborate with other service providers in reassessing the veteran's needs for non-institutional, institutional services/programs and entitlements. The social worker is 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. Resource Development- The social worker is responsible for developing a resource file of VA and community social service programs and will refer the veteran to needed services. Advocacy - Social worker understands the intimidation of bureaucracy and will act as an advocate when it serves the best interest of the veteran/family. When appropriate and feasible, social worker will educate and encourage the veteran/family to advocate on their own behalf, thus fostering a sense of independence and empowerment. Crisis Intervention - Social worker is experienced in making rapid assessments and developing crisis management plans to maintain patient in the home, for admission to acute, short term and/or long-term placements. Social worker has access to multiple resource directories in addition to previously developed resources to meet the demands of a crisis. In the event of a medical or psychiatric emergency, staff will follow the protocol of the HBPC Program. Education/Health promotion and prevention - Social worker provide 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. Coordination of non-institutional and institutional services - Social worker are responsible for the coordination of the referrals of non-institutional services such as HBPC, ADHC/CADHC, home hospice, skilled and non-skilled homecare services in collaboration with the interdisciplinary treatment team members. The social worker is also responsible for the coordination of the referrals of institutional placements in Adult Homes, Assisted Living Programs, CNH or VA-NHCU. This includes reviewing the progress notes from the other providers to accurately determine the strengths and limitations of each veteran being referred for non-institutional and institutional alternatives. Supportive counseling - Social worker will provide the veterans and their caregivers with ongoing supportive counseling. The purpose of such counseling is to deal with the psychosocial impact of coping with chronic/disabling illness(es), onset of a catastrophic illness and/or dying, need for non-institutional or institutional services as needed during the course of the veteran's enrollment in the HBPC Program. Administrative responsibilities - The social worker will enter all veteran/family contacts in the electronic record using appropriate formats and templates. This information will be entered in a complete, confidential, and professional manner to insure information on the patient is shared with other VA staff. This information will be reviewed on a regular basis. The social worker will establish and maintain positive working relationships with employees, volunteers, consumers and stakeholders within the VA and outside community agencies. Work Schedule: Monday - Friday, 8:00am - 4:30pm Virtual: This is not a virtual position. Functional Statement #: 0000/Senior Social Worker Permanent Change of Station (PCS): Not Authorized Financial Disclosure Report: Not required"]

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