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 as 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. A professional social worker assigned to the Primary Care- Patient Aligned Care Team must use a high level of skill in assessing and treating the complicated psychosocial problems of Veterans and their families/significant others. Social Work responsibilities include the assessment of psychosocial problems that cause distress, often impacting the health condition and creating barriers to care. Must complete thorough assessments to determine the underlying causes of the presenting problem, the interpersonal and environmental factors impacting the problem, and its affect on the patient's ability and desire to comply with the treatment recommendations by the multidisciplinary team. The social worker will help 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. The social worker will coordinate with VA staff and community agencies to assist in problem solving as needed. Case management with members of the outpatient interdisciplinary team is provided 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. Services include but are not limited to interventions to increase access to care, including transportation assistance and advanced directives, economic assistance, including assistance with medical bills, financial aid services and strategies to increase income (employment, vocational rehabilitation, VA benefits, disability), and/or reduce expenses, find the appropriate housing for the patient's level of need (affordable independent housing, homeless shelters, group and family care homes, Veterans Homes, assisted living, nursing homes, respite care, hospice care) and order necessary services to assist with functional decline. The incumbent will complete Caregiver Support Program home visits for veterans assigned to their work area. Work Schedule: Full-Time, Monday to Friday, 8:00 am - 4:30 pm Telework: Not Available Virtual: This is not a virtual position. Position Title/Functional Statement #:Social Worker PACT/PD52909A Financial Disclosure Report: Not required