Primary & Community Care Social Worker

Detailed Overview

• Works within an interdisciplinary team to provide comprehensive services and therapeutic clinical counseling to clients and their families;
• conducts comprehensive social work and psychosocial assessments of clients and their families using a variety of assessment tools to provide treatment services for clients including liaising with community agencies and caregiver support groups;
• provides clinical support to the interdisciplinary team including physicians in the development of care plans and services within the assigned area of responsibility;

participates on local committees and planning bodies to identify areas to improve the efficiency and effectiveness in service delivery to enhance client care services and reduce service gaps.

Responsibilities Conducts comprehensive social work and psychosocial assessments by interviewing the client and / or their family, obtaining relevant information, gathering social data and interpreting the data using a variety of tools, in accordance with professional standards, clinical policies, legislation and practices.

Provides comprehensive therapeutic services by exploring the psychosocial response to identify problems, personal concerns, treatment objectives and facilitates change in coping style, behavior, attitude and feelings;

participates with the client, families, community supports and the interdisciplinary team to coordinate services, manage cases and facilitates meetings.

Collaborates with the interdisciplinary team in client care planning by interviewing the client and / or family to assess and determine care plan and type of service required;

follows up and provides ongoing monitoring of complex psychosocial situations; evaluates client’s response to interventions.

Supports a seamless approach to care and service delivery across the healthcare system by participating in the admission and discharge process of clients in acute care and community;

arranges meetings to assist in developing and coordinating comprehensive care plans and community services for clients; collaborates with the hospital and community services to determine the effective utilization of available resources.

Partners with community services, health and social agencies including provincial Ministries, physicians and other primary care providers in the assessment and management of individuals at risk, making referrals to appropriate resources when longer term treatment or follow-up is required and exchanging relevant information.

• Facilitates timely exchange and provision of information regarding client care between the acute care facility and the community service to allow for individualized discharge planning;
• works with community service providers to ensure client care needs are met. Acts as a clinical resource for clients and their families by providing information regarding community resources and access to these resources, facilitating referrals where appropriate;
• determines if client is capable of making decisions around client care plans, in collaboration with the interdisciplinary team;

refers client to appropriate health care professional for assistance and follows procedures around client incapacity, respecting the client’s right to privacy and confidentiality.

Maintains patient records by documenting assessments, charting information and preparing progress notes and reports in accordance with established standards, policies, procedures and current regulatory requirements.

Maintains a variety of records such as workload statistics by recording information into approved formats, collating data, analyzing trends, accounting for variances, preparing reports as required and provides recommendations to the Manager, Clinical Operations or designate, as required.

Develops, coordinates and delivers in-services, presentations, psycho-educational and support groups and / or training by collaborating with members of the interdisciplinary team, determining relevant content, conducting literature searches, planning and coordinating seminars.

Participates on local committees and planning bodies to identifying opportunities for change, assess available resources, analyze outcomes and identify areas to enhance patient care services and reduce service gaps.

Initiates, develops and carries out research activities and program planning and development relevant to the needs of the patient, families, hospital and community, as assigned.

Arranges and participates in joint home visits to clients and / or families with other healthcare professionals, as required;

provides advice to the clients and / or caregiver about available community resources. Performs other related duties, as assigned.

Qualifications Education, Training and Experience Current full registration with the BC College of Social Workers. Two years' recent related experience in a complex health care environment such as a community or home health setting, or an equivalent combination of social work education, training and experience.

May Require : Valid BC Driver's License and access to personal vehicle for business-related purposes. Skills and Abilities Comprehensive knowledge and understanding of counseling and clinical practice models as it related to individuals, families and groups.

Demonstrated ability to conduct comprehensive social work and psychosocial assessment. Comprehensive counseling skills including crisis counseling, brief therapeutic interventions and loss and grief applicable to patients, families and their support networks.

Comprehensive knowledge of pertinent / relevant health care and privacy legislations. Working knowledge of First Nations, Metis and Inuit health, culture and traditions.

Ability to educate and provide consultation to patients, families and healthcare professionals. Ability to effectively work independently and with others including working effectively in a multicultural environment, as part of an interdisciplinary team.

Demonstrated ability to communicate effectively both verbally and in writing. Demonstrated ability to organize and prioritize workload in a complex environment.

Ability to operate related equipment including applicable software applications. Physical ability to carry out the duties of the position.