Summary

Works for the Central Virginia VA Health Care System - Fredericksburg Health Care Center (FxHCC) and is assigned to the Behavioral Health Interdisciplinary Program (BHIP). Duty location is: 10432 Patriot Highway Fredericksburg - VA 22408-2628.

Qualifications

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)
• A doctoral degree in social work may not be substituted for the master's degree in social work
• Experience/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
• In addition to the above - the following experience must be demonstrated: Knowledge of community resources - how to make appropriate referrals to community and other governmental agencies for services - and ability to coordinate services
• 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
• 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
• 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
• 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
• References: VA HANDBOOK 5005/120 PART II APPENDIX G39 The full performance level of this vacancy is GS-11.

Duties

• Serves in the role of the Mental Health Treatment Coordinator (MHTC) - also referred to as Care Coordinator
• Care coordination is a system-wide approach to the deliberate organization of all Veteran care activities between two or more participants or systems to facilitate the appropriate delivery of health care services
• Care coordination involves deliberately organizing patient care activities and sharing information among all participants concerned with a Veteran's care to achieve safer and more effective care
• This means the Veteran's needs and preferences are known ahead of time and communicated at the right time to the right people - and this information is used to provide safe - appropriate - and effective care to the Veteran
• The position is fully dedicated to care coordination and serves as a point of contact (POC) for Veterans receiving mental health care (other than brief mental and behavioral health care provided in integrated care settings) across the mental health continuum of care
• The primary role of the MHTC is care coordination - not direct care provision (e.g. - ongoing psychotherapy)
• The MHTC ensures Veterans receiving MH care on a BHIP team have continuity throughout their mental health care and affords Veterans a consistent POC - especially during care transitions
• Ongoing POC and clinical resource that promotes treatment engagement - especially during care transitions along the MH continuum of care
• Provides and/or ensures the Veteran (and family/caregiver/support person) has access to education - information - and resources for proactive self-management
• Complete MH Care Coordination needs assessment
• Develops initial MH Care Coordination interventions plan - including intended frequency of contact - as part of the overall care plan Documents needs assessments and interventions plan in the electronic health record (EHR)
• Monitors MH Care Coordination and treatment needs and adjusts the MH Care Coordination interventions plan - in collaboration with BHIP providers - as needed over time
• Communicates with the Patient Centered Management Module (PCMM) coordinator to ensure all MHTC assignments are current and visible in the EHR
• Participates in frequent team huddles (e.g. - daily) and team meetings (e.g. - weekly) helps to organize flow of team huddle
• Outreaches or facilitates outreach to Veteran to promote care continuity when other team members are unavailable (e.g. - triage Veteran needs)
• Provides information/education to other healthcare and service providers to facilitate recognizing and respecting the Veteran's needs - strengths - and goals
• Coordinates care within and beyond the BHIP team by including BHIP team members - other VHA healthcare providers - and community providers to ensure that key components of mental health care delivery occur consistent with policy
• Responds to critical events (e.g. - ED/UCC visits - inpatient stays - suicide behaviors - accidents - etc.) as they are known by gathering information - updating the team - coordinating any additional care or changes to care - and following up with the Veteran as needed
• Is available to the Veteran to answer questions about needs - upcoming visits - care plans - and other questions not already handled by BHIP treating provider(s)
• Flexibly provides same-day access and walk-in services (i.e. - triage) and either address immediate needs that do not require a treating team provider or facilitate a hand off to a treating team provider
• Aids in crisis intervention - as needed (e.g. - manages medical and mental health emergencies appropriately - including suicidal and homicidal ideation)
• Facilitates urgent appointments and warm handoffs - as needed - with BHIP team members
• Ensures Veteran receive needed care through ensuring consult initiation and follow-up
• Ensures consults are entered or referrals are made to providers - services - and resources appropriate to the Veteran's needs
• Monitors whether referrals made by the BHIP team to other resources are completed and whether the Veteran is engaged in the planned level of care
• Attempts outreach to the Veteran to try to increase treatment engagement
• Educates the Veteran on the team model and the Veteran's active role on the BHIP team
• Work Schedule: Monday - Friday - 8am-4:30pm Recruitment/Relocation Incentives: Not Authorized Telework: Ad Hoc - as determined by the agency policy Virtual: This is not a virtual position
• VA Careers - Social Work: https://youtube.com/embed/enRhz_ua_UU VA Careers - Licensed Clinical Social Worker: https://youtube.com/embed/U_xC25QsN0w Total Rewards of a Allied Health Professional