Social Worker - Home Based Primary Care (HBPC)

Summary

The HBPC Social Worker is a member of a multidisciplinary team providing interdisciplinary primary care in the homes of Veterans with serious medical & psychosocial behavioral conditions for whom routine clinic based care is not effective or may not be possible. They provide intensive case management & caregiver support. They also collaborate with community partners & other professional agencies in care coordination & mobilization of tailored services for the Veteran or caregiver.

Duties

• Major duties include: Performs comprehensive initial and follow-up assessments to meet the psychosocial needs of the patient and their support systems. Independently uses evidence-based screening tools and assessments. Develops the psychosocial plan of care, following advanced assessment and screening, to improve the patient's ability to achieve optimal psychosocial functioning. Partners with the interdisciplinary team to enhance the Veteran's psychosocial treatment plan, experience, and progress toward treatment goals. Responsible for crisis intervention and/or suicide prevention in home environments & functions without additional staff support or supervision in patient homes. Performs rapid assessments and develops crisis management plans. Assess for suicidality and self-harm, perform appropriate interventions, and create a safety plan for the Veteran. Assist with admission to inpatient programs as needed. Provides case management services to Veterans and facilitates integration of varied services for the treatment of complex medical, psychosocial, rehabilitative, behavioral, or palliative care needs. Supports the Veteran and caregiver in coping with all aspects of chronic disease. Assess and intervenes to address caregiver burden. Completes documentation in accordance with applicable policy and standards. Provides Veterans with evidence-based individual, family, and group psychotherapy. Coordinates the delivery of psychosocial services and provides psychotherapy to assist Veterans in coping with complex and chronic illness, functional decline, changes in condition, adjustment, caregiver burden, and bereavement. Offers education and support and encourages the Veteran/family to advocate on their own behalf, fostering a sense of independence and empowerment in the Veteran. Act as an advocate, serving the best interest of the Veteran. Implements methods for measuring effectiveness of practice and utilizes measures to improve treatment services within the Geriatrics & Extended Care Service. Establishes and maintain positive working relationships with employees, volunteers, consumers, and stakeholders within the VA and with outside community agencies. Collaborates with other service providers in assessing the Veteran's needs. Offers education to the Veteran and caregiver on available services and assists them with referrals. Coordinates care with the Veteran, their caregiver, and other relevant parties through the continuum of care. Refer and connect the Veteran to needed services. Provides expert-level consultation on advance care planning, caregiver support, and aging-in-place resources. Provides orientation and coaching to new social workers and social work graduate students. Offers training to other staff in both formal and informal settings including team meetings, grand rounds, and continuing education offerings. Operates a government vehicle in the performance of their duties, and, subsequently must maintain medical clearance from the employee health department, have a valid state driver's license, and provide proof of insurability. Work Schedule: Monday-Friday; 8am-4:30pm Recruitment/Relocation Incentives (Sign-on Bonus): Not authorized Permanent Change of Station (Relocation Assistance): Not authorized Pay: Competitive salary and regular salary increases. When setting pay, a higher step rate of the appropriate grade may be determined after consideration of higher or unique qualifications or special needs of the VA (Above Minimum Rate of the Grade). Paid Time Off: 37-50 days of annual paid time offer per year (13-26 days of annual leave, 13 days of sick leave, 11 paid Federal holidays per year) Selected applicants may qualify for credit toward annual leave accrual, based on prior [work experience] or military service experience. Parental Leave: After 12 months of employment, up to 12 weeks of paid parental leave in connection with the birth, adoption, or foster care placement of a child. Child Care Subsidy: After 60 days of employment, full time employees with a total family income below $144,000 may be eligible for a childcare subsidy up to 25% of total eligible childcare costs for eligible children up to the monthly maximum of $416.66. Retirement: Traditional federal pension (5 years vesting) and federal 401K with up to 5% in contributions by VA Insurance: Federal health/vision/dental/term life/long-term care (many federal insurance programs can be carried into retirement) Telework: Not Available Virtual: This is not a virtual position. Functional Statement #: 92136-O Permanent Change of Station (PCS): Not Authorized

Qualifications

Applicants pending the completion of educational or certification/licensure requirements may be referred and tentatively selected but may not be hired until all requirements are met. Basic Requirements: United States Citizenship: Non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy. English Language Proficiency. Candidates must be proficient in spoken and written English to be appointed as authorized by 38 U.S.C. § 7403(f). 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. Licensure. Persons hired or reassigned to social worker positions in the GS-185 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/ May qualify based on being covered by the Grandfathering Provision as described in the VA Qualification Standard for this occupation (only applicable to current VHA employees who are in this occupation and meet the criteria). Grade Determinations: In addition to the basic requirements for employment, the following criteria must be met when determining the grade of candidates. Social Worker, GS-11 (1) 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. NOTE: For appointment licensure or certification at this level please refer to paragraph 3c. OR (2) 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. (3) Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, candidates must demonstrate all of the following KSAs: (a) Knowledge of community resources, how to make appropriate referrals to community and other governmental agencies for services, and ability to coordinate services. (b) Skill in independently conducting psychosocial assessments and treatment interventions to a wide variety of individuals from various socio-economic, educational, and other backgrounds. (c) 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. (d) 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. (e) 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. (4) Full Performance Level Assignments. This is the full performance level. Social workers at this level are licensed or certified to independently practice social work. Incumbents are assigned to all program areas, including but not limited to: inpatient or outpatient medicine, surgery, mental health, neurology, rehabilitation medicine, and geriatrics. Employees provide professional, independent social work services in the assigned area. Duties include but are not limited to: assessing and documenting identified behaviors or symptoms of abuse, neglect, exploitation and/or intimate partner violence; use of clinical social work skills and knowledge to maintain Veteran privacy and confidentiality per policies, handbooks or directives; and acts as an advocate with appropriate VA and community service providers and agencies when it serves the best interest of the Veteran and family members/caregiver. Incumbent independently assesses the psychosocial functioning and needs of Veterans and their family members, identifying the Veteran's strengths, weaknesses, coping skills, and psychosocial acuity. In collaboration with the Veteran, family/caregiver, and interdisciplinary treatment team, the social worker facilitates the delivery of health care services. The social worker identifies family/caregiver stressors, conducts assessment and provides specific interventions. The incumbent provides case management and care coordination to facilitate appropriate delivery of health care services, incorporates complex multiple causation in differential diagnosis and treatment of Veterans, including making psychosocial and psychiatric diagnoses within approved clinical privileges or scope of practice. The social worker links the Veteran with services, resources, and opportunities, in order to maximize the Veteran's independence, health, and well-being. The social worker conducts timely assessment of at-risk Veterans in crisis to identify immediate needs, evaluate risk, and initiate safety plan as appropriate. The social worker provides interventions independently with Veterans and their families/caregivers who are experiencing a wide range of complicated medical, behavioral health, financial, legal, and psychosocial problems. They provide a range of interventions and treatment modalities which may include individual, group, and/or family counseling or psychotherapy. They independently formulate and implement a treatment plan including measurable, achievable goals identifying the Veterans' needs, strengths, weaknesses, coping skills, and psychosocial acuity. Social workers serve on committees, work groups, and task forces at the facility and VISN level or in the community. They provide subject matter consultation to colleagues and students on the psychosocial treatment of Veterans offering professional opinions based on experience, expertise and role modeling effective social work practice skills. The social worker establishes and maintains ongoing education programs for Veterans, community agencies, students, and staff, to facilitate understanding of social work interventions specific to the Veteran/Military population. Reference: For more information on this qualification standard, please visit https://www.va.gov/ohrm/QualificationStandards/. The full performance level of this vacancy is G-11. The actual grade at which an applicant may be selected for this vacancy is GS-11 Physical Requirements: Required to sit and stand for at least eight hours. Also, ride in a car to complete home evaluations with supervised staff. Able to lift 10 - 25 pounds of supplies related to the HBPC program.

Requirements

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 (https://www.uscis.gov/i-9-central/form-i-9-acceptable-documents). Effective May 7, 2025, driver's licenses or state-issued identification cards that are not REAL ID compliant cannot be utilized as an acceptable form of identification for employment. Must pass pre-employment physical evaluation/examination. (Driver's License Requirement) 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 "Required Documents" section of this announcement. As a condition of employment for accepting this position, you will be required to serve a 1 or 2-year trial period during which we will evaluate your fitness and whether your continued employment advances the public interest. In determining if your employment advances the public interest, we may consider: your performance and conduct; the needs and interests of the agency; whether your continued employment would advance organizational goals of the agency or the Government; and whether your continued employment would advance the efficiency of the Federal service. Upon completion of your trial period, your employment will be terminated unless you receive certification, in writing, that your continued employment advances the public interest.

Education

A transcript, either official or unofficial, must be submitted with your application for ALL degrees. A copy of your certificate/degree or screenshot of your current classes are not a replacement of your transcript and they will not be used in the qualifying process. Your transcript must include the following information: Your Name Name of the college or university Full address of the college or university Degree Received Date Conferred Note: Only education or degrees recognized by the U.S. Department of Education from accredited colleges, universities, schools, or institutions may be used to qualify for Federal employment. You can verify your education here: http://ope.ed.gov/accreditation/. If you are using foreign education to meet qualification requirements, you must send a Certificate of Foreign Equivalency with your transcript in order to receive credit for that education. For further information, visit: https://sites.ed.gov/international/recognition-of-foreign-qualifications/.

How to apply

All applicants are encouraged to apply online. To apply for this position, you must complete the full questionnaire and submit the documentation specified in the Required Documents section below. The complete application package must be submitted by 11:59 PM (ET) on 09/21/2026 to receive consideration. To preview the questionnaire click https://apply.usastaffing.gov/ViewQuestionnaire/13057067. To begin, click Apply Online to create a USAJOBS account or log in to your existing account. Follow the prompts to select your USA JOBS resume and/or other supporting documents and complete the occupational questionnaire. Click Submit My Answers to submit your application package. NOTE: It is your responsibility to ensure your responses and appropriate documentation is submitted prior to the closing date.