The Patient Aligned Care Team (PACT) is a comprehensive team which delivers primary care to Veteran patients in a longitudinal rather than episodic fashion and which has its focus: prevention; health promotion, coordination and chronic disease management. The Social Worker in this Veteran centric approach often functions as a care coordinator with a panel of Veterans to ensure that health care meets the needs, as defined by the Veteran. Uses a high level of skill in assessing and treating the complicated psychosocial problems of Veterans and their families/significant others. Assesses psychosocial problems that cause distress, often impacting the health condition and creating barriers to care. Receives referrals that typically originate from any member of the interdisciplinary team, from Veterans and/or their families who call or walk-in for assistance, and from community professionals. Completes thorough assessments to determine the underlying causes of the presenting problem(s), the interpersonal and environmental factors impacting the problem, and its effect on the patient's ability and desire to comply with the treatment recommendations by the multidisciplinary team. Helps the patient and family to understand the contributing factors to the problem(s), will discuss with them the pros and cons of possible short-term and long-term solutions, encouraging them to make positive and lasting changes to reduce stressors. Coordinates with VA staff and community agencies to assist in problem solving as needed. Provides case management with members of the outpatient interdisciplinary team in order to coordinate a collaborative effort to meet the agreed upon goals for a Veteran's treatment needs and include liaison with community professionals regarding needed services for Veterans and/or their families. Work Schedule: Monday - Friday 8:00 am - 4:30 pm Financial Disclosure Report: Not required
Internal Number: 599869800
About Veterans Affairs, Veterans Health Administration
Providing Health Care for Veterans: The Veterans Health Administration is America’s largest integrated health care system, providing care at 1,255 health care facilities, including 170 medical centers and 1,074 outpatient sites of care of varying complexity (VHA outpatient clinics), serving 9 million enrolled Veterans each year.