The Cincinnati VA Medical Center is looking for an employee who will serve as a core member of the interdisciplinary Home-Based Primary Care (HBPC) treatment team which is a specialized program under the administration of Primary Care. The individual will work autonomously and provide expert level psychosocial interventions and case management services to Veterans with complex medical, social and behavioral conditions in which routine clinic-based care is not effective.
The Cincinnati VA Medical Center (CVAMC) is a two-division campus located in Cincinnati, OH and Fort Thomas, KY serving 15 counties in Southwest OH, Northern Kentucky, and Southeast Indiana with 6 Community Based Outpatient Clinics located in Bellevue, KY; Florence, KY; Lawrenceburg, IN; Hamilton, OH; Clermont County, OH, and Georgetown, OH.
The CVAMC also supports two off main campus locations in the Cincinnati area via an Eye Center and Mental Health Outreach Community Division. Duties: Provides a comprehensive psychosocial assessment and integrates it into an overall plan of care in collaboration with the interdisciplinary treatment team, the Veteran, family members and significant others, whenever possible.
Possesses the advanced practice skills to independently make a psychosocial diagnosis and offer psychosocial interventions, and then measures outcomes to interventions. Participates and can lead weekly interdisciplinary care planning meetings when asked by the HBPC program director. Addresses the unique needs of homebound, frail, disabling/chronic and/or dying Veterans.
Coordinates community-based services, including information and referral for additional services from other VA programs, other government programs and community agency programs. Facilitates and prioritizes referrals based upon Veterans needs and eligibility.
Provides 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. Identifies and prioritizes high-risk patients and provides case management services.
Provides crisis intervention services, seeking to address the cause as well as the presenting complaint, coordinates family conferences and serves as liaison to family members. Establishes and maintains effective therapeutic relationships with Veterans and their families. Possess advanced knowledge and ability to independently implement treatment modalities, provide counseling or psychotherapy for individuals, families and groups.
Utilizes advanced practice skills, professional judgment and expertise regarding the Veteran's self-care capability, family support system, and the Veteran's health care needs and possible consequences. Provides consultation services to other staff regarding the psychosocial needs of Veterans and the impact of psychosocial problems on health care and adherence to treatment plan.
Evaluates own practice through professional peer review, case conferences and other organizational means. Incumbent is able to communicate effectively, both orally and in writing, with people from varied backgrounds. Provides the Veterans and their caregivers with ongoing supportive counseling utilizing the advanced knowledge of and mastery of theories and modalities. Enters all Veteran/family contacts in the electronic record using appropriate formats and templates.
Assumes a leadership role in the HBPC program and periodically review and update documentation templates to ensure compliance with regulatory guidelines, social work standards of practice, and VHA policies. Reviews, updates and writes policies, procedures, and/or practice guidelines periodically pertaining to the specialty population or specialty treatment program based on experience and evidence-based practice research.
Establishes and maintains positive working relationships with employees, volunteers, consumers and stakeholders within the VA and outside community agencies. Collaborates in the performance improvement processes and support performance measures as required by the VA for their specialized population and/or program. Serves as a subject matter expert to colleagues, providing professional opinions and support for psychosocial treatment of this complex population when consulted.
Supervises graduate students and provides a training experience for them in the Social Work Service. Work Schedule: Monday - Friday, 7:30 am to 4:00 pm Telework: AD HOC, per agency policy discretion. Virtual: This is not a virtual position. Functional Statement #: 91268-0 Relocation/Recruitment Incentives: Not Authorized. Permanent Change of Station (PCS): Not Authorized.
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/.
This position is with Veterans Health Administration, Department of Veterans Affairs.
The posted pay range is $93231 – $121203/yr.
Applications close on 2026-10-16.
This position is open under the 'Fed Internal Search' hiring path.
Source: USAJOBS.gov — U.S. Federal Government
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