The Patient Aligned Care Team (PACT) Social Worker provides clinical services in the Primary Care Clinic at the VA Medical Center and Community Based Outpatient Clinics
VA Careers - Social Work: https://youtube.com/embed/enRhz_ua_UU The Patient Aligned Care Team (PACT) delivers primary care to Veterans in a longitudinal rather than episodic fashion and which focuses on prevention, health promotion, coordination, and chronic disease management. The PACT Social Worker in this Veteran-centric approach primarily functions as a direct-care provider for all psychosocial and behavioral health issues with assigned panels of Veterans.
The PACT Social Worker also functions as a care coordinator to ensure that access to and services provided for healthcare meets the needs of the Veteran, as defined by the Veteran/Caregiver. The PACT Social Worker is uniquely prepared for the role by virtue of education, training, and experience which prepares the incumbent to understand the person-in-situation and the influences that family and community have in impacting the healthcare needs of Veterans.
Major duties include but not limited to: Identify problems, strengths, weaknesses, coping skills and needed assistance. Provide psychosocial support to Veterans with highly complex health and/or mental health problems and the provision of short-term, solution focused counseling with Veterans and/or their families. Make rapid assessments and developing crisis management plans for Veterans in crisis.
In the event of a medical or psychiatric emergency, the PACT Social Worker will follow the protocol of the VA Medical Center or corresponding Community Clinic. Maintain access to approved resource directories in addition to previously developed resources to meet the demands of a crisis. Work in conjunction with the PCMHI staff or other Mental Health staff to ensure a warm handoff where appropriate in the event of a requested admission to mental health inpatient programs.
Complete appropriate clinical reminders and screening tools for assessing suicide risk. As appropriate, will complete Comprehensive Suicide Risk Evaluations (CSRE) and Safety Plans. Function as a vital member of the interdisciplinary follow-up team for any Veterans flagged as high risk for suicide and work closely with the PCMHI staff or other Mental Health staff at their clinic for appropriate warm handoffs when needed.
Represent the VA with professionalism and respect to both internal and external stakeholders. Acts as a subject matter expert on VA and/or community resources. Collaborate with other service providers in assessing the Veteran's needs as appropriate. Educate Veterans and/or caregiver of the available services and assisting them in establishing the appropriate referrals based on the Veteran's preference or that of their authorized surrogate decision-maker.
Utilize current VA and community social service programs and enhancing the content to the benefit of Veterans. Serve as a liaison with community agencies, assist Veterans (or caregivers) with referrals for services from community and government agencies, and help coordinate these services, when appropriate. Coordinate with other VA staff and community agencies to assist in problem solving as needed.
Run psychotherapeutic and psychoeducational groups for Veterans, caregivers and/or family members Function as an independent provider within the PACT. Act as a care coordinator and case manager for psychosocial concerns related to psychosocial determinants of health for Veterans assigned to their panel.
Work in conjunction with the Senior PACT Social Workers and the Primary Care Social Work Supervisor to ensure that psychosocial, mental health and social work services are provided appropriately to all patients throughout the healthcare system.
Conduct psychosocial assessments in collaboration with the interdisciplinary treatment team, the Veteran patient, family members and significant others; interviewing Veterans and family members/significant others and writing the psychosocial assessment. Ensure biopsychosocial assessments highlight Veterans' strengths, limitations, and internal/external supports and service needs to optimize their functional status.
Assess and treat the complicated psychosocial and behavioral health problems of Veterans, caregivers and their families/significant others. Assess, treat, and appropriately refer for the psychosocial problems that cause distress, which often impact the health condition and create barriers to care.
These stressors can include adjustment to the current medical condition, untreated or under-treated mental health or substance abuse condition, economic instability, legal problems, and inadequate housing and transportation. Accept referrals from any member of the interdisciplinary team, Veterans, caregivers and/or family members who call or walk-in for assistance, and from community professionals.
Work Schedule: 8:00am - 4:30pm Monday - Friday Telework: This position is eligible for telework on an Ad- Hoc Basis per agency policy Functional Statement #: GS 9: 08133F/ GS 11: 654 - 09406-F
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/.
omar.smith2@va.gov · 9155647517
This position is with Veterans Health Administration, Department of Veterans Affairs.
The posted pay range is $97545 – $153435/yr.
Applications close on 2026-09-28.
This position is open under the 'Public' hiring path.
Source: USAJOBS.gov — U.S. Federal Government
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