Primary Care Mental Health Integration (PCMHI) is a component of the interdisciplinary Patient Aligned Care Team (PACT). The incumbent serves as the PCMHI Collaborative Care Manager (PCMHI CoCM) Social Worker (SW). The PCMHI Collaborative Care Manager (PCMHI CoCM) Social Worker (SW) provides evidence-based, condition specific (e.g., depression), protocol-driven services to collaboratively assist PACT providers in treating common mental health and health behavior concerns in primary care.
Basic Requirements: Citizenship. Be a citizen of the United States. English Language Proficiency. Candidates must be proficient in spoken and written English to be appointed. Education. Have 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. A doctoral degree in social work may not be substituted for the master's degree in social work. Verification of the degree can be made by going to http://www.cswe.org/Accreditation to verify that the social work degree meets the accreditation standards for a masters of social work. Licensure. Persons hired or reassigned to social worker positions in the GS-0185 series in VHA must be licensed or certified by a state to independently practice social work at the master's degree level. Current state requirements may be found by going to http://vaww.va.gov/OHRM/T38Hybrid/. GS-9 Experience, Education, and Licensure. None beyond the basic requirements. Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, the candidate must demonstrate all of the following KSAs: Ability to utilize counseling skills when working with Veterans and family members. 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. GS-11 Experience and Licensure. Appointment to the GS-11 grade level requires completion of a minimum of one year of post-MSW experience equivalent to the GS-9 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, candidates must demonstrate all of the following KSAs: 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. Preferred Experiences: Experience with the PCMHI model Physical Requirements: Physical demands of the work are generally minor, as the position requires sitting, standing, and walking. There is the possibility that travel between clinic sites could be required as clinical tasks demand. The emotional demands can be stressful in working with high-risk for suicide veteran population and their families. A high level of self-awareness is essential. Work, divided between office and clinical settings, is primarily sedentary. May require prolonged standing, moderate walking, and manual dexterity. Requires carrying light items, such as books, files, or laptop computer. References: VA Handbook 5005, Appendix G39. Social Worker Qualification Standard, GS-185.
Major Duties Include, but are not limited to: Patient outreach and engagement in treatment Patient contact is frequently provided via telephone and written correspondence, however face-to facecare is within the scope of this position Initial assessment of the Veteran, including the following: Administration of validated patient reported outcome measures Review of assessments and documentation completed by others Obtain missing pertinent information from providers, patients, and medical records Development of an individualized treatment plan using standardized algorithms to guide treatmentrecommendations and support evidence-based decision making Keep current with knowledge of the variety of clinical options available through the medical centerand local community about how to refer/engage Veterans Review of initial assessment and treatment plan with the PCMHI Provider with Prescribing Privilegesconsultant and PCP, incorporating modifications of the plan as recommended Routine use of a patient registry, including: Entry of all Veterans receiving PCMHI CoCM into a registry (e.g., Behavioral Health Lab software) Use of a registry to ensure patient follow-up, track engagement in PCMHI CoCM protocols, andmonitor treatment response Run patient registry reports to facilitate care provision and to monitor quality of care Participation in weekly caseload consultation with the consulting PCMHI Provider with Prescribing Privileges Actively seek out additional ad-hoc consultation as clinically indicated. Providing education and brief interventions using evidence-based techniques such as behavioral activation, motivational interviewing, and other focused treatment strategies Monitoring of Veteran progress using validated patient reported outcome measures Ongoing review of progress and recommendations for changes in treatment, including medication adjustments, utilizing evidence-based algorithms in consultation with the PCMHI Provider with Prescribing Privileges Relapse prevention planning throughout care, including transition from active treatment to maintenance as goals are achieved Timely and thorough documentation of all patient interactions Provision of same-day access to PCMHI services Ongoing collaboration with and coordination of the Veteran's care with the treating PCP and otherhealthcare professionals Influence adherence to evidence-based treatment guidelines in PACT by providing "on-time, ontarget"information to PACT providers Function effectively within interdisciplinary teams, fostering open communication, mutual respect, and shared decision-making to achieve quality patient care Continuously collaborate with the entire PCMHI team to ensure high quality, effective, Veteran-centered services at the patient and programmatic levels. Complete PCMHI Functional Assessments and work with the PCMHI team and PACT to engage Veteran in the most appropriate level of follow-up care within available resources. Collaborate with PCMHI leadership/team members to develop/enhance educational materials and use marketing strategies to promote PCMHI CoCM services. Effectively communicate with patients, families, caregivers, VA leadership, and members of the interdisciplinary team Participation in weekly supervision with assigned clinical supervisor for case review and discussion of clinical decision making and treatment planning with the expectation for regular outreach to supervisor to discuss any clinical cases that require more immediate review. Performs other appropriate clinical duties as assigned Work Schedule: Monday-Friday, 8:00am - 4:30pm Telework: Not Authorized Virtual: This is not a virtual position. Functional Statement #: 554-52920-A Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized Financial Disclosure Report: Not required