Inpatient Social Worker

Inpatient social workers are assigned to medical, surgical, critical, and specialty care inpatient teams. Services include both primary and secondary care health care services, to include, but not limited to, psychosocial screening and assessment, discharge planning, care coordination, health education and advanced health care planning, and supportive counseling. Inpatient social workers work closely with other members of the interdisciplinary treatment teams.

The social worker conducts comprehensive psychosocial screenings and assessments of the veteran in collaboration with the interdisciplinary treatment team, the veteran, family members, and significant others. The goal is to understand the veteran's situation, presenting problems, their causes, and the impact on the veteran's level of functioning and health. This assessment highlights the veteran's strengths, limitations, high-risk factors, acuity levels, and internal/external supports and service needs to optimize functional status. It includes attention to self-care deficits, acopia of the veteran and/or caregivers, abuse, neglect, exploitation, intimate partner violence, and frail elderly indicators. The initial assessment, as well as reassessments, must be completed as specified by policy.

The social worker works closely with veterans to align care with their preferences and treatment goals, collaborating with the interdisciplinary treatment team, the veteran, and family members. This includes a range of psychosocial treatments such as supportive counseling for veterans and caregivers, information and referral for financial and resource needs, and the involvement of palliative and hospice care services.

The social worker provides case management and care coordination during episodes of emergency care and other specific needs. This involves acting as a health coach, supporting self-care, and ensuring the provision of clinical and psychosocial services. The social worker coordinates supportive services such as temporary lodging and transportation, acts as a liaison between treatment programs, and ensures smooth transitions for veterans receiving community and after-care services.

The social worker identifies health education needs and works with the interdisciplinary team to create plans addressing these needs. Education includes disease information, treatment options, symptom management, and advance health care planning such as advance directives and living wills. For specialized education outside of their scope, the social worker refers to the appropriate team members.

The social worker acts as an advocate, addressing bureaucratic challenges and fostering independence and empowerment in veterans and their families.

The social worker is adept at rapid assessments and crisis management planning, utilizing multiple resources to address emergency situations effectively.

The social worker is responsible for developing, updating, and reassessing discharge plans, treatment plans, and treatment goals with the veteran and/or their family/caregiver. This involves collaboration with other service providers and educating the veteran regarding the available services and appropriate referrals.

The social worker uses and enhances the social work resource file of VA and community social service programs to benefit veterans, making necessary referrals for needed services.

The social worker reviews progress notes to determine the strengths and limitations of each veteran referred for community health services. They educate the veteran, family, and the team about available options to collaboratively choose the preferred service.

The social worker provides ongoing supportive counseling to veterans and their families to address the psychosocial impact of illness and coping with chronic or catastrophic conditions.

You must be a U.S. citizen to apply for this job. All applicants tentatively selected for VA employment in a testing designated position are subject to urinalysis to screen for illegal drug use prior to appointment. Applicants who refuse to be tested will be denied employment with VA. Selective Service Registration is required for males born after 12/31/1959. Must be proficient in written and spoken English. You may be required to serve a trial period. Subject to background/security investigation. Selected applicants will be required to complete an online onboarding process.