Social Worker

Summary Social Workers within the Patient Aligned Care Team (PACT) model serve as integral care team members, functioning as care coordinators for an assigned panel of Veterans. They are responsible for assessing and addressing a broad spectrum of biopsychosocial needs that influence health outcomes, including mental health, housing instability, financial hardship, caregiver burden, food insecurity, and access to community resources. Responsibilities The Patient Aligned Care Team (PACT) is a comprehensive, interdisciplinary model designed to provide longitudinal, Veteran-centered primary care with an emphasis on prevention, health promotion, chronic disease management, and care coordination. Within this framework, the social worker functions as an essential care coordinator for an assigned panel of Veterans, ensuring that care aligns with each Veteran's individual needs, goals, and values. Social workers apply advanced clinical skills, and a holistic perspective rooted in the person-in...

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