Job Description
The Clinical Social Worker is an integral member of the Sinai Health to Home (SHtoH) team at Circle of Care. With a focus on integrated care and the social determinants of health, the social worker works within the program guidelines to support patients recently discharged from Sinai Health. The program is intended to provide wrap-around services to support the transition from hospital to home and optimize functional recovery through self-efficacy and chronic disease management. In order to touch as many lives as possible and positively impact patient and family outcomes while on the program, social workers will provide trauma informed and culturally sensitive practice to align with the program goals for equity and sustainable health care.
The Social Worker partners with the patient and family to address their transitional goals within the program guidelines and as part of the interprofessional team. They provide community referrals and linkage to available resources to address patient/family ongoing social needs and promote effective coping through transitions in care until discharged from the program.
We are looking for: a full-time, permanent Clinical Social Worker
Salary: Commensurate with experience
Hours of Work: 34 hours/week. This role is community based (in-home visits) with some requirements to work in office and in a virtual capacity from home.
Reports to: Manager, Client Services
Responsibilities
Client Service Experience
- Mutually develop SMART goals with the patient/family within the program guidelines.
- Document/report on social service sensitive outcomes to contribute to program success.
- Work with patients and their families in accordance with RNAO best practice guidelines for person centered care.
- Provide trauma informed care that is culturally sensitive to people who identify as vulnerable (indigenous, LGBTQ+, disabled, frail, low income, mental health, and addictions).
- Keep the Program Supervisor informed about patient/family feedback, decline of services, patient risk situations or inability to meet KPIs.
- Provide information, and counselling to patient/family regarding their plan of care and program expectations.
- Provide in home visits and virtual visits as needed within the program catchment area Monday to Friday. May be required to meet outside of regular business hours to meet patient needs.
Evidence Informed Practice and Quality Improvement
- Apply a strengths-based perspective and view patients and their families as resourceful, resilient, and having capacity.
- Focus on improving health and social well-being using the social determinants of health framework.
- Conduct a comprehensive assessment, including the InterRAI-CA instrument, for new patients.
- Set SMART goals that can be realistically met within the program guidelines.
- Provide supportive counselling or make appropriate community referrals.
- Contribute to social work and program quality improvement initiatives.
- Follow program guidelines for identification of risk and adopt verbal reporting requirements.
Information Management and Reporting
- Clinical documentation in accordance with organizational policies and procedures, including legislated and college requirements.
- Complete InterRAI-CA instruments, as part of their assessment process, with patients newly admitted to the program within 24 hours of discharge from Sinai Health.
- Document accurate, thorough, and timely patient information in the information management system not associated with requirements for health records.
- Prepare and submit Professional Service Reports within three days of the patient’s initial assessment, when requested as a Change of Status update and after goals are completed and the patient is discharged from their service.
Team Building and Clinical Leadership
- Use therapeutic communication, effective collaboration skills and patient advocacy within the program guidelines and funder expectations.
- Support and work cohesively in an integrated team lead by the Program Supervisor.
- Attend daily huddles as required and provide consistent feedback to the Program Supervisor about the patient/family experience and progress with goal completion.
- Act as a change agent to positively encourage others and manage change.
Relationships with External Partners
- Ensure that funded Social Work services are aligned to funder program guidelines and that patients/families receive consistent messages about program goals and services.
- Actively develop and promote trust-based and collaborative partnerships with external community support service organizations throughout the program catchment by warm handoff (person to person) referrals.
- Escalate to external social partners for urgent patient needs such as food.
Relationships with Internal Partners
- Attend regular meetings with Social Work team for peer case review.
- Work as part of the integrated team with Hospital to Home and Circle of Care.
Risk, Health and Safety Management
- 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.
Qualifications
- Masters, Social Work required, BSW with healthcare focus from an accredited institution.
- Registered and in good standing with the Ontario College of Social Workers and Social Service Workers.
- 2 years of clinical experience in a healthcare patient service environment.
- Clinical experience providing care in the community, home care, and direct patient care.
- Understanding of gerontological and mental health issues and experience with the seniors’ population particularly related to diagnosis of cognitive impairment.
- Knowledge of community resources, health care, and social service systems.
- Strong advocacy, decision making, and problem-solving skills.
- Strong person-centered focus, negotiation, and conflict resolution skills.
- Excellent interpersonal and oral/written communication skills.
- Proven bias for action, excellent critical thinking, and time management skills.
- Competency with Microsoft Office environment.
- Self-starter, work well independently and within a dynamic team.
- Must have valid Drivers License and access to a vehicle.
- French language proficiency is an asset.
Additional information
Circle of Care is committed to fostering an inclusive, accessible environment, where all employees, volunteers and clients feel valued, respected and supported. We are dedicated to building a workforce that reflects the diversity of the communities in which we live and serve, and creating an environment where every employee has the opportunity to reach their potential. Circle of Care seeks applicants who embrace our values of equity, anti-racism, and inclusion. As such, we encourage applications from candidates who have been historically disadvantaged and marginalized, including but not limited to those who identify as First Nations, Métis and/or Inuit/Inuk, Black, members of racialized communities, persons with disabilities, women and/or 2SLGBTQ+.
We are committed to an environment that is barrier free. If you require accommodation, please inform us in advance.
We thank you for your interest in Circle of Care. We welcome you to apply for this role, even if you do not meet every requirement listed. Only applicants who are selected for an interview will be contacted.
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