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 The VA Northern California Health Care system is currently recruiting a Transitions of Care Senior Social Worker for the Primary Care service in the Martinez location. The Transitions of Care Senior Social Worker addresses the Veteran's bio-psychosocial status, social system, and resources. This social worker further develops and maintains a therapeutic relationship with the Veteran, which may include linking the Veteran with systems that provide needed services, resources, and opportunities. The social worker demonstrates his/her expertise by navigating complex health and social service systems, combined with his/her unique psychosocial perspective, in helping Veterans and their families/caregivers access resources, to maximize the Veteran's independence, health, and well-being. The social worker collaborates closely with the Veteran, the Veteran's family, the Transitions of Care RN, and the Transition of Care pharmacist to provide the most comprehensive approach to case management services when both complex medical and psychosocial factors are identified that may adversely impact the Veteran's health. This relationship minimizes duplication of services and unnecessary handoffs as each discipline brings their unique perspective to ensure that all of the Veteran's bio-psychosocial needs are met. Major duties include, but are not limited to: Supports the Veteran, the Veteran's family, and the Veteran's caregiver's health needs across episodes of care both within and outside the VA Health Care System. Develops rapport with community hospitals providing care to veterans such that care coordination during transition is optimized. Interacts with members of the health care team within a facility while assessing, communicating, facilitating care, and advocating. Communicates with unit staff to identify learning needs specific to the Veteran and discharge planning needs, especially those unique or essential to a Veteran's health condition or care situation. Facilitates communication between the Veteran, the Veteran's family/caregiver, VA health care providers, and among the Veteran's various health care providers. Establishes, in collaboration with key stakeholders (e.g., providers, payers, employers, family, and significant others), comprehensive case management goals, objectives, and expected outcomes including specified times frames. Conducts thorough assessments to determine psychosocial problems that cause distress, often impacting the health condition and creating barriers to care needs of Veterans and family members, the underlying causes of the presenting problem, the interpersonal and environmental factors impacting the problem, and its effect on the patient's ability and desire to comply with the treatment recommendations. Helps the Veteran and family understand the contributing factors to the problem(s), discusses with them the pros and cons of possible short-term and long-term solutions, and encourages them to make positive and lasting changes to reduce stressors. Provides consultation and education to Veterans and their families regarding community resources, VA benefits and specialty programs, and advance directives/LSTD. Identifies appropriate resources and provides referrals to various service resources along a continuum of care to restore or maintain Veterans independent functioning to the fullest extent possible. Shares data and information, seeks clarification, individualizes treatment plans and interventions, and monitors outcomes of the Veteran's treatment and effectiveness of the program. Collaborates with the health care team to ensure acquisition of the appropriate non-skilled services and community resources necessary to meet the unique health and psychosocial needs of the Veteran. Work Schedule: Monday through Friday 8AM to 4:30PM Telework: Telework, if approved, would be on a regularly scheduled basis, but this is not a virtual or remote position. Virtual: This is not a virtual position. Functional Statement #: PD000000 Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized Financial Disclosure Report: Not required
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.