| *Incentives Not Available* The Home and Community Based Services (HCBS) Program Coordinator is a social worker who is responsible for maximizing psychosocial quality of life issues in order to assist Veterans to remain in their home or in a less restrictive level of care and keep them out of the hospital as often as possible. The incumbent serves Veterans who tend to have serious, frequent, and severe crises; lack family or adequate community support networks, poor at self-monitoring; frequently fail to comply with instructions and treatments; have significant deficits in coping skills and require continuing psychosocial and medical support. Roles, responsibilities, and duties of the HCBS Program Coordinator are broken into the following areas: Program Management. Responsible for the overall function of the assigned HCBS Program. The incumbent oversees program development, quality improvement projects, written and oral communication between internal and external customers, assessment, counseling and recommending to Veterans and caregivers, case management, development of policies and care processes, and coordination with HCBS interdisciplinary treatment teams. Identify community agencies, establish intake processes, establish oversight responsibilities, and maintain a record-keeping system for the program. Market the model of care and reach out to community groups and agencies to promote program expansion with the Veterans Administration. Serve as a mentor to other HCBS coordinators, social workers, and other interested health care providers. Have extensive knowledge of geriatrics, community agencies and partnerships, and VA HCBS programs to include Homemaker Home Health Aide Respite, Purchased Skilled Home care, Home Based Primary Care, Veteran Directed Home And Community Based Services, Hospice, Palliative Care, Geriatric Evaluation and Management, Community Nursing Home, State Veterans Home, Caregiver Support, Geriatric and Extended Care policies and procedures, VHA and VBA regulations. Screening/Assessment. Receive and complete consults from interdisciplinary teams and VA Primary Care teams on complex, difficult cases, using advanced practice skills and expertise. Document in medical records utilizing paper and/or electronic formats, including psychosocial assessments, diagnostics, treatment, progress notes, follow up, and referrals. Interview Veterans and family members and/or significant others to establish facts about the Veteran's unique situation, presenting problems and their causes, and the impact of such problems on the Veteran's functioning and health as a part of a comprehensive psychosocial assessment. Assess high risk factors, acuity and need for services, and interpret and explain VA treatment and benefit programs. Review all data, subjective and objective, and make a clinical assessment identifying needs and strengths. Use advanced clinical training, insight, and experience to interpret data and to identify viable options. Treatment Planning. Develop psychosocial treatment plans in collaboration with HCBS interdisciplinary team, including goals for psychosocial treatment. Using known available resources and the initial assessment of the Veteran's likelihood to accept differing types of assistance, make initial and continuing decisions regarding use of VA and non-VA services and referrals. These decisions are based on the social worker's advanced practice skills, professional judgment, and expertise regarding the Veteran's self-care capability, family support system, the Veteran's health care needs and possible consequences; including medical foster home placement. Evaluation and Management. Establish a continuing relationship with community agencies, caregiver and Veteran, and involved family members, evaluating progress towards goals and adjusting the program plan as appropriate. Evaluate on an on-going basis the needs of Veterans as progress is made or Veteran health condition changes. Monitor progress, maintain comprehensive documentation, ensure expert diagnosis and treatment of clinical disorders, and show competent discretion in decision to adjust treatment. Make recommendations for care and changes to interdisciplinary treatment plan. Provide patient and/or caregivers and family members with ongoing supportive counseling. The purpose of such counseling is to deal with the psychosocial impact of coping with chronic/disabling illnesses, onset of a catastrophic illness and or dying; need for non-institutional or institutional services as needed during the patient's enrollment in HCBS programs. Advocacy. Act as an advocate when it serves the best interest of the Veteran/family. The program coordinator will act as an advocate for the VA and need for services in specific geographical areas. At all times the incumbent will represent the VA in the community in a positive and professional manner. Crisis Intervention. The program coordinator is experienced in making rapid assessments and developing crisis management plans to maintain the Veteran. In the event of an alleged abuse case, medical or psychiatric emergency, the protocol of the medical center policy will be followed. Work Schedule: Mon - Fri, 8:00 am to 4:30 pm. Financial Disclosure Report: Not required. |
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