Social Worker (Family Health Team)

Carefirst Seniors & Community Services Association•Toronto, ON

17d•Hybrid

About The Position

The Carefirst Family Health Team (FHT) is seeking a Full-time permanent / Part-time permanent Social Worker to join their innovative, interdisciplinary team dedicated to delivering high-quality, community-based care. Carefirst FHT is committed to delivering exceptional, comprehensive primary care through a collaborative, team-based model that includes family physicians, nurse practitioners, nurses, social workers, service navigators, dieticians, physiotherapists, and medical receptionists. They have a robust Chronic Disease Management and Prevention program, including a Diabetes Education Program, and are actively involved in many of the Ontario Health Team’s primary care initiatives. Their “Hub & Spoke Model” and strong community partnerships ensure coordinated, high-quality, patient‑centred care across the continuum. They work closely with Carefirst Seniors & Community Services Association to provide truly integrated services. On‑site & Integrated Programs/Services include: Ontario Health atHome (formerly Home and Community Care Support Services), MINT Memory Clinic, Ontario Structured Psychotherapy (OSP) Program, and Specialist Clinics (psychiatry, cardiology, endocrinology, optometry, geriatric medicine, gynecology, chiropody, rheumatology, physiotherapy, and audiology). They operate four well-established clinics across Scarborough, Markham and Richmond Hill, and continue to expand in Markham and Stouffville. Employees will be assigned to a location that aligns with their preferences and residence, with occasional rotation to support clinic operations.

Requirements

Master of Social Work from an accredited institution
Current registration and in good standing with the Ontario College of Social Workers and Social Service Workers
At least 3 years clinical case management experience, in a primary health care/community-based setting
Demonstrated case management and coordination experience
Familiar with in-home health care and assisted living services
Experience in developing, implementing, monitoring, and evaluating health promotion programs and activities
Outstanding assessment skills and ability to exercise good judgment and instincts in order to understand patient/client needs
Proficiency in current assessment, psychotherapy and psychosocial counselling techniques, including proficiency in the use of Cognitive Behavioural Therapy, strong holistic assessment skills, and Mindfulness Techniques
Ability to interpret social, emotional and behavioral problems as related to medical conditions, and to develop appropriate treatment plan
Sensitivity and awareness of cultural, racial, economic, and socially diverse communities of various ages
Strong ethical standards and discretion handling sensitive information
Valid CPR/first aid certification
A valid vulnerable sector police record check completed within one year

Nice To Haves

Experience in couples counselling and Geriatrics/working with seniors
Experience treating sexual abuse/assault as well as complex trauma
Experience in teaching social work students and other interdisciplinary learners
Experience with Electronic Medical Record (EMR) systems, InterRAI CHA Assessment and other data-based applications (AlayaCare)
Ability to speak a second language such as Cantonese and/or Mandarin

Responsibilities

Coordinate and manage Carefirst’s various programs and services as they pertain to social work
Provide leadership and consultation to a team of social workers including supervisory work related to staff and daily operations
Assist with the development and implementation of social work policies and procedures
Interact with community agencies involved in health and social services, represent Carefirst at meetings and events in the community
Act as convenor for case conferences and be responsible for chart auditing on a routine basis
Monitor and evaluate the overall performance of the social work team
Assess and triage social work referrals
Monitor targets and compile quarterly statistic reports
Conduct eligibility and service needs assessments
Develop, initiate and coordinate individualized care plans for eligible patients/clients and provide ongoing resource management, case management and discharge planning as appropriate
Provide client-centered care through administration of comprehensive patient needs
Perform psychosocial assessments, diagnosis and therapeutic intervention/counselling to patients to assist them to achieve optimum social functioning and psychological wellbeing
Offer counselling services, with particular regard to individual and family issues and decisions that impact the health of patient and family
Advocate for patients and their families in matters affecting health
Identify and support access to community, volunteer and professional services and programs appropriate to patient/client needs
Perform other duties as available: practicum supervision, collaboration opportunities etc.