Social Worker - Home Based Primary Care

Department of Veterans Affairs•Battle Creek, MI

35d•Hybrid

About The Position

The Battle Creek VA Medical Center is recruiting to fill a Social Work position in Home Based Primary Care (HBPC) serving the Battle Creek or Benton Harbor catchment area. They provide high quality case management, psychosocial support, advocacy, and linkage with appropriate VA and community service providers/agencies as needed.

Requirements

Applicants selected for a position that requires travel must possess a current and valid driver's license.

Responsibilities

Developing the treatment plan and setting achievable treatment goals with the veteran/family in collaboration with the HBPC interdisciplinary treatment team members
Developing a resource file of VA and community social service programs and will refer the veteran to needed services.
Collaborating with other service providers in reassessing the Veteran's needs for non-institutional, institutional services/programs and entitlements.
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.
Act as an advocate when it serves the best interest of the Veteran/family.
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.
Coordinating referrals of non-institutional services such as 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 Community Residential Care, Assisted Living Programs, or a community nursing home.
Entering all Veteran/family contacts in the electronic record using appropriate formats and templates.
Attend all meetings (weekly interdisciplinary treatment team meetings, Social Work staff meetings, Rehab and Extended Care staff meetings, assigned committees, etc.) and perform other duties as required by Extended Care and the Home Based Primary Care.
Other duties as assigned.