Social Worker - Home Based Primary Care (HBPC)

Veterans Health Administration • Fort Wayne, IN

4d • Hybrid

About The Position

The Social Worker serves as a core member of the interdisciplinary Home-Based Primary Care (HBPC) treatment team, a specialized outpatient Patient Aligned Care program. The incumbent independently provides psychosocial interventions and case management to Veterans with complex medical, social, and behavioral conditions for whom routine clinic-based care is not effective. Patients generally have impaired mobility or difficulty coping with clinic settings and need frequent coordinated care from multiple disciplines. Care is delivered in the patient’s home, with government vehicles available for travel to residences.

The role uses advanced practice skills, knowledge, and judgment to develop and evaluate social work services and improve treatment through outcome evaluations. The Social Worker coordinates specialized services and programs and performs case-management activities including outreach, interdisciplinary coordination, psychosocial assessments, treatment planning, and consultation and education for facility staff and community service providers. Home visits are made to Veterans within a 60-mile radius of the assigned campus, as assessed by the interdisciplinary team.

The position is at the GS-11 level. A master’s degree in social work from a CSWE-accredited school and state licensure or certification to independently practice social work at the master’s level are basic requirements. The GS-11 grade requires at least one year of post-MSW experience equivalent to GS-9 in health care or another social-work-related setting and independent-practice licensure or certification, or a doctoral degree in social work in place of the experience requirement. The position requires home visits and the physical ability to navigate homes that may have obstacles, stairs, pets, unsafe structures, or other safety and infection-control risks. The schedule is Monday through Friday, 8:00 a.m. to 4:30 p.m.; telework is ad hoc under agency policy, and this is not a virtual position.

The position is eligible for the Education Debt Reduction Program, subject to individual eligibility and application review. The program may provide up to $200,000, with an eligibility period of one to five years. Other listed offerings include competitive salary and regular increases, paid time off, paid parental leave after 12 months, a childcare subsidy for eligible full-time employees after 60 days, federal pension and 401(k), and federal health, vision, dental, term life, and long-term care insurance.

Requirements

• Master’s degree in social work from a school fully accredited by the Council on Social Work Education (CSWE).
• State licensure or certification to independently practice social work at the master’s degree level; credentials must be maintained.
• For GS-11, at least one year of post-MSW experience equivalent to GS-9 in health care or another social-work-related setting, plus independent-practice licensure or certification; alternatively, a doctoral degree in social work may substitute for the experience requirement.
• Knowledge of community resources and ability to make appropriate referrals and coordinate services.
• Ability to independently conduct psychosocial assessments and treatment interventions with people from varied backgrounds.
• Knowledge of medical and mental health diagnoses, disabilities, treatment procedures, common medications and their effects or side effects, and medical terminology to formulate treatment plans.
• Ability to independently implement treatment modalities with individuals, families, and groups experiencing psychiatric, medical, and social problems.
• Ability to consult with new social workers, social work graduate students, and other staff about patients’ psychosocial needs and the effects of psychosocial problems on health care and treatment compliance.
• U.S. citizenship, subject to the stated exception for recruitment of qualified citizens.
• Proficiency in written and spoken English.
• Must pass a pre-employment physical evaluation or examination and meet applicable background, security, and onboarding requirements.
• Must participate in the seasonal influenza vaccination program and meet annual Employee Health requirements.
• Must be physically able to navigate home structures and perform potentially extended periods of walking, standing, stooping, sitting, bending, pulling, and pushing; transferring patients and objects may be required.
• Must be able to work effectively in stressful situations and shift priorities based on patient needs.
• Must comply with Selective Service registration requirements, if applicable.

Nice To Haves

• Current, unrestricted LCSW.
• Home-based care experience.
• Experience with geriatric populations.

Responsibilities

• Provide psychosocial interventions and case management independently to Veterans with complex medical, social, and behavioral conditions.
• Conduct home visits and coordinate care with the interdisciplinary HBPC treatment team.
• Develop and evaluate social work practice and services, using outcome evaluations to improve treatment services.
• Coordinate specialized services and programs.
• Conduct outreach and psychosocial assessments, and develop treatment plans.
• Coordinate interdisciplinary activities and refer Veterans to appropriate community and governmental services.
• Provide consultation and education to health care facility staff and community-based service providers.
• Assess home safety, including environmental, physical, emotional, and spiritual aspects.
• Complete required annual Employee Health requirements.

Benefits

• Education Debt Reduction Program, subject to eligibility and approval, with an award of up to $200,000 and an eligibility period of one to five years.
• Competitive salary and regular salary increases.
• 37–50 days of annual paid time off per year, comprising 13–26 days of annual leave, 13 days of sick leave, and 11 paid federal holidays.
• Potential credit toward annual leave accrual for prior work or military service, subject to request and approval.
• Up to 12 weeks of paid parental leave after 12 months of employment, in connection with birth, adoption, or foster-care placement of a child.
• Childcare subsidy after 60 days for eligible full-time employees with total family income below $144,000, covering up to 25% of eligible childcare costs, subject to a monthly maximum of $416.66.
• Traditional federal pension with five-year vesting and federal 401(k), with up to 5% in VA contributions.
• Federal health, vision, dental, term life, and long-term care insurance; many federal insurance programs may be carried into retirement.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level