Social Worker - Patient Aligned Care Team (PACT)

U.S. Department of Veterans Affairs; San Antonio (TX); Hybrid; USD 60,000 - 85,000; Full time

Job summary

The U.S. Department of Veterans Affairs seeks a PACT Social Worker to deliver Veteran-centered primary care across our San Antonio facilities. The role emphasizes prevention, health promotion, education, care coordination, and chronic disease management within the PACT framework and VA policies.

The position requires a CSWE-accredited MSW, state licensure, and strong collaboration with interdisciplinary teams to implement SMART goals and comprehensive services for Veterans and their families.

Qualifications

• Master's degree in social work from CSWE-accredited program.
• Licensed or certified to independently practice social work.
• English language proficiency required (spoken and written).

Responsibilities

• Assist Veterans in navigating care and ensuring follow-up with the PACT team.
• Complete psychosocial assessments and coordinate care with Veterans and families.
• Educate Veterans on VA benefits, services and community resources.
• Provide case management and facilitate timely community placements with inter-disciplinary teams.
• Respond to consults and participate in peer review or care coordination activities.

Skills

Veteran-centered care

Crisis intervention

Assessment skills

Education

Master's in Social Work

State licensure

Job description

Summary

The PACT Social Worker provides Veteran-centered primary care focused on prevention - health promotion - education - care coordination - clinical services - and chronic disease management. They support Veterans across various primary care areas - help set Specific - Measurable - Achievable - Relevant - and Time-bound (SMART) goals - and deliver comprehensive services using their training and VA/STVHCS policies.

Summary

The PACT Social Worker provides Veteran-centered primary care focused on prevention - health promotion - education - care coordination - clinical services - and chronic disease management. They support Veterans across various primary care areas - help set Specific - Measurable - Achievable - Relevant - and Time-bound (SMART) goals - and deliver comprehensive services using their training and VA/STVHCS policies.

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
• English Language Proficiency: You must be proficient in spoken and written English as required 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 4 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
• Grandfathering Provision: 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 and meet the criteria)
• The following is the standard grandfathering policy for all title 38 hybrid qualification standards
• All persons employed in VHA in this occupation on the effective date of this qualification standard (9/10/2019) are considered to have met all qualification requirements for the title - series and grade held - including positive education and licensure or certification that are part of the basic requirements of the occupation
• For employees who do not meet all of the basic requirements in this standard - but who met the qualifications applicable to the position at the time they were appointed to it - the following provisions apply: Such employees in an occupation that requires a licensure or certification - may be reassigned - promoted up to and including the full performance (journey) level - or changed to lower grade within the occupation - but may not be promoted beyond the journey level or placed in supervisory or managerial positions
• Employees who are appointed on a temporary basis prior to the effective date of the qualification standard may not have their temporary appointment extended or be reappointed - on a temporary or permanent basis - until they fully meet the basic requirements of the standard
• Employees initially grandfathered into this occupation - who subsequently obtain additional education and/or licensure/certification/registration that meet all of the basic requirements of this qualification standard must maintain the required credentials as a condition of employment in the occupation
• If an employee who was retained in an occupation listed in 38 U.S.C.
• 7401(3) under this provision leaves that occupation - the employee loses protected status and must meet the full VA qualification standard requirements in effect at the time of reentry to the occupation
• Grade Determinations: Social Worker - GS-9: Experience - Education - and Licensure: None beyond the basic requirements
• Demonstrated Knowledge - Skills - and Abilities
• In addition to the experience above - the candidate must demonstrate all of the following KSAs: Ability to utilize a Veteran centric approach when providing interventions and counseling for Veterans - their family members - caregivers - and survivors
• Ability to assess the psychosocial functioning and needs of Veterans and their family members - and to formulate and implement a treatment plan - identifying the Veterans problems - strengths - weaknesses - coping skills - and assistance needed
• Ability to implement treatment modalities in working with individuals - families - and groups to achieve treatment goals
• This requires judgment and skill in utilizing supportive - problem solving - or crisis intervention techniques
• Ability to establish and maintain effective working relationships and communicate with clients - staff - and representatives of community agencies
• Fundamental knowledge of medical and mental health diagnoses - disabilities - and treatment procedures
• This includes acute - chronic - and traumatic illnesses/injuries
• common medications and their effects/side effects
• and medical terminology
• Social Worker - GS-11 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
• Examples of specialized experience include but are not limited to: Working under close supervision in program areas that do not require specialized knowledge or experience
• Identifying behaviors or symptoms of abuse - neglect or exploitation
• providing education on advance directives and advanced care planning
• providing social work case management
• acting as an advocate with community service providers/agencies when it serves the best interest of the patient and family members/caregiver
• assessing the psychosocial functioning and needs of patients and their family members identifying strengths - weaknesses - coping skills and psychosocial acuity - in collaboration with the patient - family - and interdisciplinary treatment teams
• maintaining a current network of internal and external resources to educate the patient and/or family members/caregivers and assist with the appropriate referrals
• OR 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
• Demonstrated Knowledge - Skills - and Abilities: In addition to the experience or education above - candidates must demonstrate all of the following KSAs: 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 - educational - and other 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 - 8 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.

Duties

• Please note that duty stations include : Audie L
• Murphy Memorial Veterans' Hospital - 7400 Merton Minter Boulevard - San Antonio - TX 78229-4404 Northeast Bexar VA Clinic 2391 Northeast Loop 410 Suite 309 San Antonio - TX 78217 North West San Antonio VA Clinic - 9939 State Highway 151 - San Antonio - TX 78251-1900 Shavano Park VA Clinic - 4350 Lockhill-Selma Road - Suite 200 - San Antonio - TX 78249-2166
• Major Duties include but are not limited to: - Assist PACT Veterans in navigating care - accessing services - and ensuring follow-up with the PACT team
• - Serve as liaison between VA providers and community agencies
• - Complete psychosocial assessments and coordinate care - linking Veterans and families with needed resources
• - Identify caregiver/family stressors and provide interventions or referrals
• determine appropriate case-management level
• - Assess at-risk Veterans in crisis - evaluate needs - and initiate safety plans
• - Build and maintain professional relationships within VA and community partners
• - Provide consultation to staff on Social Work programs
• - Educate Veterans on obtaining a PACT provider and using VA services (VVC - MyHealtheVet - Whole Health - Community Care)
• - Conduct assessments via phone - VVC - or in person
• - Provide case management for high-acuity or high-need Veterans (e.g. - high CAN scores)
• - Protect Veteran privacy and confidentiality per policy
• - Assess and document signs of abuse - neglect - exploitation - or intimate partner violence
• - Participate in facility - VISN - or community committees and work groups
• - Demonstrate knowledge of PACT roles - homelessness factors - discharge planning - and community placement options
• - Facilitate timely community placements with Veterans - families - and interdisciplinary teams
• - Provide consultation to treatment teams on psychosocial factors affecting care and compliance
• - Educate Veterans on VA benefits - services - and community/governmental resources
• - Promote and complete Advance Care Planning and Advance Directives
• - Respond to consults within required timeframes using multiple care modalities
• - Follow suicide-risk procedures including C-SSRS - CSRE - Safety Plans - and SBOR completion
• - Participate in peer review - case conferences - or research to evaluate Social Work practice
• - Support telework - clinic coverage - and care for unassigned Veterans as needed
• - Perform additional duties as assigned
• Work Schedule: Monday - Friday - 7:30 a.m
• - 4: 00 p.m
• or 8:00 a.m
• - 4:30 p.m
• Telework: Ad-hoc telework may be available as determined by the agency policy
• Virtual: This is not a virtual position
• Functional Statement #: PD53794-F and PD53793-F Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized