Social Worker - Community Living Center Discharge Planner

The incumbent will provide medical Social Work services to the Veteran population within Geriatrics and Extended Care (GEC), primarily providing discharge planning services for the Community Living Center (CLC) at Dom VA Medical Center. Services include provision of high-quality case management, clinical treatment, advocacy, and coordination of linkages to other appropriate VA or community service providers.

Major duties

Duties may include but not limited to: Develops an assessment of the Veteran in collaboration with the interdisciplinary treatment team, the Veteran, family members and significant others. Develops and demonstrates an understanding of the range of treatment and skills needed for all adult patients including geriatric patients related to their physical limitations, psychological needs and age associated illnesses and conditions. Develops a treatment plan with the Veteran, based on their assessment/screening. Develops the treatment plan and discharge plan and setting achievable treatment/discharge goals with the Veteran/family. Attends treatment team meetings and complete all MOS entries and the Social Work Care Plan for team meetings in a comprehensive and timely manner. Reviews discharge plans weekly, and communicates discharge needs to all members of the treatment team as appropriate. Collaborates with other service providers in assessing and reassessing the Veteran's needs. Educates the Veteran, family and or significant others 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. Makes rapid assessments and develops crisis management plans for admission to mental health inpatient programs when appropriate. Provides education related to VA and community resources, entitlements, Advanced Directives/Living Will and will refer Veterans/families to the appropriate interdisciplinary team member for identified health education needs. Provides the Veterans and their caregivers with ongoing supportive counseling. Enters all Veteran/family contacts in the electronic record using appropriate formats and templates. Establishes and maintains positive working relationships with employees, volunteers, consumers and stakeholders within the VA and outside community agencies. Performs other duties as required. Work Schedule: Monday-Friday, 8:00am-4:30pm Telework: Not Available Virtual: This is not a virtual position. Functional Statement #: 58847F & 58843F Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized

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: In accordance with 38 U.S.C. 7402(d), no person shall serve in direct patient care positions unless they are proficient in basic written and spoken English. Education: Must hold 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. Note: A doctoral degree in Social Work may NOT be substituted for the master's degree in social work. Licensure: Must be licensed or certified by a state to independently practice social work at the master's degree level. 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. For appointments at the GS-9 grade level, VHA social workers who are not licensed or certified at the time of appointment must become licensed or certified at the independent, master's level within three years of their appointment as a social worker. A social worker who does not yet have a license that allows independent practice must be supervised by a licensed independent practitioner of the same discipline who is a VA staff member and who has access to the electronic health record. 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). Grandfathering Provision. The following is the standard grandfathering policy for all title 38 hybrid qualification standards. Please review the qualification standard to determine the specific education and/or licensure/certification/registration requirements that apply to this occupation. All persons employed in VHA in this occupation on the effective date of this qualification standard 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.(5) 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. 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. NOTE: If social workers covered under the grandfathering provision of the 1991 Federal law regarding licensure or certification of VHA social workers leave the GS-0185 social work series, they lose the grandfathering protection. If they choose to return at a later date to the GS-0185 series, they must be licensed or certified to qualify for employment as a social worker. Grade Determinations: Social Worker, GS-09 Experience, Education, and Licensure - None beyond the basic requirements listed above. Demonstrated Knowledge, Skills, and Abilities - In addition to the experience above, the candidate must demonstrate all of the following KSAs (must be clearly demonstrated in your resume): 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 post-MSW experience equivalent to the GS-09 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. 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 above, the candidate must demonstrate all of the following KSAs (must be clearly demonstrated in your resume): 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, 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.

Education

Note: Only education or degrees recognized by the U.S. Department of Education from accredited colleges, universities, schools, or institutions may be used to qualify for Federal employment. You can verify your education here: http://ope.ed.gov/accreditation/. If you are using foreign education to meet qualification requirements, you must send a Certificate of Foreign Equivalency with your transcript in order to receive credit for that education. For further information, visit: https://sites.ed.gov/international/recognition-of-foreign-qualifications/.

Requirements

You must be a U.S. Citizen to apply for this job. Selective Service Registration is required for males born after 12/31/1959. Must be proficient in written and spoken English. Subject to background/security investigation. Selected applicants will be required to complete an online onboarding process. Acceptable form(s) of identification will be required to complete pre-employment requirements (https://www.uscis.gov/i-9-central/form-i-9-acceptable-documents). Effective May 7, 2025, driver's licenses or state-issued identification cards that are not REAL ID compliant cannot be utilized as an acceptable form of identification for employment. Must pass pre-employment physical examination. Participation in the seasonal influenza vaccination program is a requirement for all Department of Veterans Affairs Health Care Personnel (HCP). Complete all application requirements detailed in the "Required Documents" section of this announcement. As a condition of employment for accepting this position, you will be required to serve a 1 or 2-year trial period during which we will evaluate your fitness and whether your continued employment advances the public interest. In determining if your employment advances the public interest, we may consider: your performance and conduct; the needs and interests of the agency; whether your continued employment would advance organizational goals of the agency or the Government; and whether your continued employment would advance the efficiency of the Federal service. Upon completion of your trial period, your employment will be terminated unless you receive certification, in writing, that your continued employment advances the public interest.