- Incorporation of complex multiple causation in differential diagnosis and treatment in Veteran patients, including making psychosocial and psychiatric diagnoses within approved clinical privileges or scope of practice.
- Provision of individual, group and family counseling or psychotherapy and advanced level case management interventions used in the treatment of veterans with complex medical and psychiatric disorders in either inpatient or outpatient basis.
- Participation as an active member of the Palliative Care interdisciplinary treatment teams to provide social work interventions to veterans and/or their families to meet treatment goals within the context of their goals of care.
- Participation in and development of HPC bereavement support programs for the families of veterans who die at Mather Hospital or Martinez CLC Hospice Unit, in conjunction with the Chaplain service.
- Participation in active case finding for the Palliative Care section.
- Provision of consultation and education to other treatment teams, staff members, and the community at large regarding hospice and palliative services, and role modeling effective social work practice skills.
- Helping the Veteran cope with end-of-life or complex chronic illness diagnoses and assessment of treatment options and when appropriate making referrals based on the Veteran's preference or that of the surrogate decision-maker.
- Facilitating family discussions regarding illness, healthcare and life changes.
- Supporting end-of-life planning/care preferences through assistance with Advanced Directives for Healthcare and completion of goals of care conversations.
- Making rapid assessments and developing management plans in periods of crisis for Veteran's and their families.
- Providing education and referrals where appropriate related to the patient's VA, Social Security, disability benefits, and community resources.
- Where appropriate, referral to and coordination of hospice care services including facilitation with Non-VA Community Care Coordination.
- Having knowledge of and making referrals to a wide range of community services, including Medical Foster homes, group and family care homes, Assisted Living Facilities, Adult Day Health Care programs, Contract Nursing Homes, Community Living Centers, residential care homes, and inpatient and outpatient hospice services.
- Acting as the representative and liaison of Hospice and Palliative Care from the facility to the greater community.
- Participation in specialty committee meetings and initiatives.
- Attending to administrative duties including entering all Veteran and support system contacts in the electronic medical record in a complete, confidential, and professional manner using appropriate formats and templates.
- Develops and implements methods for measuring effectiveness of social work practice and services in the Palliative Care specialty area, utilizing outcome evaluations such as the Bereaved Family Survey to improve treatment services.
- Supports compliance of the Palliative Care Program with Joint Commission and Office of Inspector General standards for the provision of palliative and hospice care.
- The incumbent demonstrates the ability to provide training, orientation, and guidance within clinical practice and mentor staff and students in the specialty area of practice and provide supervision for licensure.
- Performs other related duties as assigned
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Social Work Coordinator - Martinez, United States - Department Of Veterans Affairs
Description
Summary
The Palliative Care Social Worker Coordinator is a professional specialized social worker assigned to the Geriatrics and Extended Care Service and aligned with the Palliative Care Section and Hospice and Palliative Care (HPC) Consult Teams
Duties
Work Schedule: Full Time; Monday - Friday, 8:00 a.m. - 4:30 p.m.; Subject to change to meet the needs of the Agency
Telework: Authorized; if approved, would be on a regularly scheduled basis but this is not a remote position.
Virtual: This is not a virtual position.
Functional Statement #: 000000
Relocation/Recruitment Incentives: Not Authorized.
Permanent Change of Station (PCS): Not Authorized
Financial Disclosure Report: Not required
The incumbent of this position must use a high level of skill in assessing and treating the complicated psychosocial problems of veterans with complex physical and mental symptoms and life-limiting illnesses. Referrals typically originate from other members of the Hospice and Palliative interdisciplinary team and services may be provided in a variety of settings including outpatient consultative clinic, inpatient acute care and intensive care units, emergency department, community living center, or BHICU, via telephone or video contact or face-to-face visits. Services are provided both to qualified veteran patients as well as their families, medical surrogates, and caregivers.
Primary responsibilities include:
