Social Worker-Home Based Care

Summary The Home Base Care (HBC) Clinical Social Worker is assigned to the St. Cloud VA Health Care System Rehabilitation Extended Care Integrated Clinical Community (REC ICC). The incumbent is an integral part of the overall VHA health care program and as part of the health care service delivery to Veterans and their families. Responsibilities VA Careers - Social Work: The incumbent will provide social work services for Veterans in the St. Cloud, Glencoe, or Community Based Outpatient Clinic (CBOC) HBC service area. Incumbent will provide social work services to adult and geriatric Veterans enrolled in the HBC Program with high quality case management, assessments, clinical treatment, advocacy, and will coordinate linkage with appropriate VA and community service providers / agencies as needed by the Veteran. CLINICIAL FUNCTIONS: A. Conducting behavioral health and mental health biopsychosocial assessments. B. Making sound professional judgments regarding clinical impressions, treatment approaches, and treatment planning. C. Coordinating with internal and external professionals to ensure appropriate transitions of care and appropriate/ necessary treatment is provided/offered to Veterans. D. Establishing and maintaining knowledge of VA and Veteran's benefits and services, community resources, and process for making appropriate referrals to community and other governmental programs or agencies. E. Providing advocacy to overcome potential barriers to access care/services and when it is in the best interests of the Veteran F. Provides goals of care discussions, as well as education and assist in the completion of Advance Directives; Organ, Tissue, and Eye Donation release of information forms; and Guardianship documentation. G. Assesses for signs and symptoms of abuse, neglect and exploitation. H. Conducts practice in accordance with the VA and discipline specific ethical requirements and practices within the limits of current licensure or certification. I. Completing on-call duties, as assigned and per policy, which may include transportation of a Veteran. ADMINISTRATIVE FUNCTIONS A. Possesses and demonstrates ability to communicate effectively, both orally and in writing with people from varied backgrounds. B. Possesses skills in using computer systems and the internet for Veterans who choose this modality to communicate. C. Serves on supervisor approved committees, work groups, and task forces at the local facility, VISN or national level. Collaborates in performance improvement processes and complies with performance measures as required by the VA for specific population/program. D. Attends and participates in all required administrative and clinical meetings. E. Maintains accurate, timely, and complete clinical records in accordance with professional practice and VA administration guidelines. F. Maintains data and statistical compilations to comply with accreditation bodies such as CARF and Joint Commission, and VA health care systems policies and procedures. ROLE-SPECIFIC TASKS A. Develop an assessment of the Veteran in collaboration with the interdisciplinary treatment team, the Veteran, and family members/significant others, whenever possible. The goal of the assessment is to highlight the Veteran's strengths, limitations, and internal/external support and service needs in order to optimize the Veteran's functional status and safely maintain the veteran in his/her home. The assessment will include a home visit. The initial assessment and assessment updates will be completed as specified by the policy for the assigned work area. B. Provide the Veterans and their caregivers with ongoing supportive counseling. The purpose of such counseling is to deal with the psychosocial impact of coping with chronic/disabling illness(es), onset of a catastrophic illness and need for non-institutional or institutional services, as needed, during the course of the veteran's enrollment in the HBPC Program. C. Coordinate the referrals of non-institutional services such as HBPC, HBMC, ADHC/CADHC, home hospice and skilled and non-skilled homecare services in collaboration with the interdisciplinary treatment team members. The Social Worker is also responsible for the coordination of referrals for institutional placements in Adult Homes, Assisted Living Programs, CNH or VA-CLC. This includes reviewing progress notes from the other providers to accurately determine the strengths and limitations of each Veteran being referred to for non-institutional and institutional alternatives. The Social Worker will educate the Veteran, their family members/significant others and the team of all the options available to them and will collaborate with the Veteran and family members/significant others on the preferred option. Work Schedule: Monday-Friday 7:30am-4pm Telework: Not Available Virtual: This is not a virtual position. Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized Requirements Conditions of Employment 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 (Effective May 7, 2025, driver's licenses or state-issued dentification cards that are not REAL ID compliant cannot be utilized as an acceptable form of identification for employment. Must pass pre-employment driving 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

Created: 2026-04-13