| Clinical social worker assigned to the Patient Aligned Care Team (PACT), General Medicine & Specialty Care Clinics, Emergency Department and SW Triage Walk-in Clinic. Referrals to the Outpatient PACT/GM & Specialty Care SW typically originate from members of the interdisciplinary treatment team, from Veterans, families, caregivers, guardians, community professionals, and VA Ann Arbor staff members in the form of consults, phone calls, walk-ins, emails and electronic medical record alerts. The Patient Aligned Care Team (PACT) is a multidisciplinary team which delivers primary care to Veteran patients using a patient centered, strengths based approach to disease prevention, health promotion and improvement, care coordination, and disease management. The PACT SW utilizes a bio-psycho-social perspective to assists Veterans and their families/caregivers in resolving psychosocial, emotional and economic barriers to achieving health and well-being while building on their strengths and abilities. The PACT SW often functions as the care coordinator with VHA and Non-VHA community partners to ensure Veterans are receiving the appropriate level of care and services to include home care/skilled home care, Sub Acute/SNF/Long Term Care referrals, Assisted Living and Adult Foster Care. The PACT/ GM & Specialty Clinic SW functions as the subject matter expert with regards to VHA/VBA/ Federal, State and local government programs, benefits and services available to our Veteran population. Further, the incumbent has enhanced knowledge and experience with providing education and assistance to Veterans, family members and medical team staff on Advanced Directives, guardianship/conservatorship processes and VA Fiduciary programs. Overall responsibilities includes the provision of direct Veteran centered patient care, concrete social services, medical care coordination, case management services, collaboration with the relevant interdisciplinary treatment team(s) and utilization of VHA, VBA, and community resources to most appropriately meet the needs of the clientele. Demonstrates a high level of skill in assessment, intervention and treatment plan development when addressing the comprehensive psychosocial needs of the Veterans He/She is assigned. The incumbent will assess the patient in order to identifying emotional, social, physical, familial, economic instability, and vocational needs that may be causing distress and impacting the health condition or creating barriers to the patient receiving recommended care/treatment. Stressors can include adjustment to the current medical condition, untreated or under-treated Mental Health or Substance Abuse condition, economic instability, legal problems, inadequate housing and transportation, abuse/neglect and exploitation. The incumbent must complete a thorough assessment to determine the underlying causes of the presenting issue(s), interpersonal and environmental factors, the patient's functional acuity and its effect on the patient's ability and desire to comply with treatment recommendations by the multidisciplinary treatment team Provide a thoughtful approach to assist the patient/ family to understand the contributing factors to the identified issue(s), discuss available short/long term solutions and/or resources, using a strengths-based empowerment model to formulate an appropriate patient centered intervention plan to reduce stressors, improve health and reach health related goals. Actively participate as a member of the interdisciplinary treatment team and actively participate through collaboration with Veterans/family/caregivers/Non-VA providers. The incumbent must be available to provide consultation to treatment team and staff members regarding psychosocial needs of Veterans, the impact of the identified psychosocial barrier on the Veteran's health care planning and compliance with treatment and available interventions/programs/services available to assist in resolving identified barriers. Identifies appropriate VHA/VBA/community resources and facilitate utilization of and linkage to these resources by the veteran and family in order to assist clientele in reaching optimal functioning. Responsible for supporting the mission, policies and procedures of the Department of Veterans Affairs, VA Ann Arbor Healthcare System, the Social Work and Community Based Services and the NASW Code of Ethics. Work Schedule: Monday-Friday (8:00 a.m. to 4:30 p.m.) Financial Disclosure Report: Not required |
