HomeVA Spinal Cord Injury SystemSCI Support Clinic/Primary Care Team in the Non-SCI CenterSCI Coordinator Role

6.4. SCI Coordinator Role

The Chief of Staff at each VA medical center without an SCI Center designates the social worker member of the SCI/D Support Clinic or SCI/D PCT as the SCI Coordinator.
  1. The social worker selected as Coordinator must have, or be willing to acquire, appropriate knowledge about:
    1. SCI treatment and rehabilitation;
    2. Physical and psychosocial implications for the individual and family;
    3. Appropriate clinical interventions, including sexual counseling;
    4. Prosthetic services;
    5. VHA policies affecting Veterans with SCI;
    6. VA benefits and other government entitlement programs for treatment, rehabilitation, and services;
    7. Community resources and services for the disabled; 
    8. Local peer counseling programs or groups; and 
    9. Federal laws or regulations regarding the disabled.
  2. The name and location of the SCI Coordinator must be posted in the Admissions and Ambulatory Care area, and listed in the medical center telephone directory.
  3. Arrangements must be made for the designated SCI Coordinator to receive specialized training to include a visit to the designated SCI Center.
  4. When developing the SCI Coordinator's functional statement, the specialized training, independent functioning, and complex and unpredictable caseload requirements warrant consideration of an advanced practice General Schedule grade. At least .5 FTE needs to be allotted for the position of the SCI Coordinator, or 1.0 FTE, if caseload is 100 or more patients with SCI/D.
  5. The SCI Coordinator must be knowledgeable about all aspects of SCI and able to provide information to patients, families, the SCI Support Clinic, or SCI PCT. It is important that the Coordinator have the ability, insight, imagination, and drive to:
    1. Assist the Veteran with SCI/D in planning and coordinating needed services;
    2. Provide consultation and teaching; and
    3. Establish and maintain effective working relationships with local management, other disciplines and services, as well as with a variety of community organizations.
  6. The SCI Coordinator is responsible for:
    1. Facilitating appropriate and timely transfers to SCI Centers.
    2. Identifying new and established Veterans with SCI who come to the medical center, and developing a procedure for referral to the SCI Center.
    3. Providing support to the SCI Support Clinic or SCI/D PCT and SCI Center.
    4. Ensuring that a current assessment (based on a comprehensive social database) is completed and indicated psychosocial treatment and services are provided and documented in CPRS. This includes appropriate counseling, educational information and referrals to VA and community resources and services, and, as appropriate, to the vocational rehabilitation case manager.
    5. Preparing a current psychological, social, and vocational assessment and treatment plan based on a comprehensive psychological, social and vocational data base. This assessment includes identification of psychological, social, and vocational treatment and services to be provided with emphasis on:
      1. Present living arrangement (i.e., housing type, access and mobility barriers, caregiver status, caregiver attitude and experience, and health of the caregiver).
      2. Support systems (i.e., family (origin and current), peer group, other community systems).
      3. Educational, vocational, and avocational interests, levels of attainment, and work history.
      4. Behavior patterns, coping and/or defense mechanisms, and sexual adjustment.
    6. Referring all Veterans with SCI/D to the Veterans Benefits Counselor and, with the Veteran's consent, to a Veteran Service Officer (VSO).
    7. Developing a system of outreach to extend services to Veterans with SCI/D not using VA for their health care needs. This involves maintaining contact with local SCI programs, VSOs, the community, and the nearest VA SCI Center.
    8. Establishing and maintaining the SCD Registry or SCIDO database of Veterans with SCI/D in the primary service area of the medical center.
    9. Organizing services to Veterans with SCI and reporting programmatic difficulties to the Chief, SCI Service, of the appropriate catchment area.
    10. Using the SCD-Registry in daily practice to identify Veterans with SCI/D admitted to, or discharged from, the medical center. NOTE: This information is to be used for consultative visits, appropriate referrals, and sharing of pertinent discharge information with the SCI Centers, as deemed needed.
    11. Acting as a consultant to other staff members in developing individualized rehabilitation plans.
    12. Establishing liaison with, and fostering involvement of, physicians, nurses, and other disciplines, as appropriate.
    13. Using existing quality management mechanisms, national policies, local policies, procedures, and external reviews in evaluating and documenting this program's effectiveness.
    14. Ensuring that Progress Notes reflect treatment progress and goal changes. This includes a closing summary when treatment is completed or a patient is transferred.


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