About the position

The Social Worker is accountable for a seamless service experience that meets the individual needs of the client and/or family, compliance with legislation through proper documentation, and has the ability to communicate with various levels within the organization in a clear and concise manner. The Social Worker works in collaboration with hospital and community partners to provide linkages with rehab options, home and community support services, geriatric services and care navigation, and caregiver support. The Social Worker works closely with client intake, consultation, and service delivery staff, and leads by example, demonstrating professionalism and enthusiasm in all dealings.

Responsibilities

• Ensure that clients and their families experience a high quality and responsive social work service.
• Work closely with hospital inter-professional teams, OHAH, Care Coordinators, and other community support roles.
• Provide information, advice, and support to the client and the family regarding the plan of care.
• Perform assessments for additional home and community support services that may benefit the client and their family beyond what they currently have or OHAH is offering to put in place.
• Review triage referrals with team members.
• Conduct ongoing assessments of client’s needs while on your caseload and adjust care plan.
• Provide short-term counselling to the client/caregiver and initiate support linkages with community resources, both internally and externally.
• Coordinate and facilitate diverse support groups to address clients’ needs and promote mutual support and connection.
• Coordinate service requirements and advocate on behalf of the client/caregiver to ensure the receipt of appropriate and timely services.
• Lead and participate in consultation services and case conferences with service providers to discuss care plans and service needs.
• Prepare and ensure accurate, thorough and timely recording of client information including reports, correspondence, legal forms, and ensure all information is up to date in the information management system and documented in accordance to departmental policies and procedures and legislation and College requirements.
• Compile and complete case files documents in preparation for discharge.
• Develop and implement appropriate short and long-term care plans for the client/caregiver based on the results of the assessment tool used within the organization.
• Build rapport for agency vision and departmental goals/objectives by communication, collaborating and leading by example.
• Demonstrate the ability to support and work cohesively in a team environment.
• Look for daily opportunities to highlight the connection between overall strategy and day-to-day activities.
• Provide consistent communication and feedback to the Team and the Manager and Senior Management where appropriate.
• Act as a change agent to positively encourage others and manage change.
• Be a resource to support integration demonstration projects being developed.
• Provide educational opportunities and clinical consultation with internal and external service providers.
• Actively develop and foster trust-based and collaborative partnerships with external customers and key organizations.
• Identify opportunities to demonstrate Circle of Care, Sinai Health System’s (SHS), UHN service assets and commitment to excellence to key funders.
• Identify and develop opportunities to expand market share in the area of social work and related services.
• Actively participate in program development, support community outreach and service initiatives for the program, and assist in building and maintaining networks with community agencies, groups, and resources as appropriate.
• Actively participate on Community-based committees/projects and ensure that Circle of Care’s assets, interests and desires are represented and listened to.
• Act as a Community Resource Expert to educate patients, families, and staff about care options within the community that they may not be aware of. This includes generating educational materials that can help other staff in supporting care transitions.
• Provide service/process communication to key internal stakeholders, inclusive of expectations, problem solving and troubleshooting support.
• Lead and/or participate on internal cross-functional project teams to lend skills, competence, and product knowledge.
• Lead by example with internal partners and demonstrate the organizational values in all personal behaviors.
• Deliver community health, home care, and support services education and training to staff.
• Identifying and reporting health and safety incidents and concerns in a timely manner to the appropriate supervisors and/or funders, documenting incidents in EasyCare and escalating appropriately to the designated supervisors as outlined in the Client Safety Reporting policy (C.01.38).
• Participating in health and safety processes and procedures.
• Participating in maintaining a safe workplace environment by cultivating a positive safety culture and encouraging best practices to promote both staff and client safety and well-being.
• Participating in all health and safety training initiatives on a regular basis.
• Taking proactive action against client incidents within your scope of practice.
• Developing a plan to identify, manage and/or minimize client safety risks or situations in adherence with risk management operations policies.
• Assessing the severity of an adverse client safety/risk event and determining the best follow-up and developing an action plan following the event. Collaborating with funder (ex. HCCSS) and following any additional processes as required.
• Calling emergency services (911) when the client is at an immediate risk of harming themselves or others, or if there is a serious injury and/or imminent harm.
• Evaluating any potential hazards and identifying clients at risk for adverse health and safety events, taking preventative measures when necessary to minimize reoccurrence.
• Reporting all safety events impacting clients, caregivers and families in a timely and honest disclosure.

Requirements

• MSW or BSW degree with a healthcare focus from an accredited institution; or equivalent. Additional qualifications may be needed based on program or funder specific requirements.
• Registered and in good standing with the Ontario College of Social Workers and Social Service Workers.
• 2+ years of experience in a healthcare client service environment.
• Clinical experience in community care, home care, or case management experience.
• Understanding of gerontological and mental health issues as well as experience with the seniors’ population particularly related to diagnosis of cognitive impairment.
• Knowledge of community resources, health care, and social service systems.
• Strong advocacy skills and a person-centered focus, strong decision making, problem recognition, problem solving skills, negotiation, and conflict resolution skills.
• Excellent interpersonal and communication skills.
• Strong client and customer focus.
• Proven bias for action, excellent critical thinking and time management skills.
• Intermediate skills in an automated environment and with the Microsoft Office environment, inclusive of Excel and Power Point.
• Ability to travel to various worksites on a regular basis and to respond to emergency situations.
• Ability to provide field educational and practicum students of related discipline.
• Must be a self-starter, work independently and within a dynamic team, and able to work with a variety of patients across the spectrum.