Social Worker - Integrated Comprehensive Care Program

St. Joseph's Home Care•Hamilton, ON

5d•CA$23 - CA$51•Hybrid

About The Position

The Social Worker - ICCP (SW-ICCP) program will provide psychosocial assessment, counselling/psychotherapy, case management, Patient/family education, supportive care, discharge planning, service coordination and consultation according to best practice standards in order to assist the client in achieving optimum recovery and quality of life. This role supports Sr. Manager - ICCP in the efficient and effective operations of the program activities, as well as providing leadership in high-risk social situations, program development, advocacy and developing and maintaining strong community linkages. Registered Social Workers will also participate in mentoring community development, teaching, continuous quality improvement and research activities. Clients are typically individuals who have been discharged from hospital to their own home, but who still require some clinical care for a short period of time. These clients are in process of having long-term care needs assessed, are medically stable, can be of any adult age group, and may require mechanical or 2-person lifts. Clients can have variable care plan timelines.

Requirements

Bachelor’s Degree in Social Work from an accredited University, required
Registered with the Ontario College of Social Workers and Social Service Workers, required
Minimum one year recent and related experience, required
Maintaining on-going compliance to corporate policies and procedures, health and safety regulations, and relevant external standards
Participating in both internal and external training requirements
Participating in quality improvement initiatives
Maintaining the privacy and confidentiality of all personal health records (including both client and personal), and following all the privacy and confidentiality requirements of all electronic medical record systems used (including but not limited to Procura and HPG)

Nice To Haves

Membership with the Ontario association of Social Workers, preferred
Gentle Persuasive Approach training, preferred
Previous experience using mobile tools and devices, preferred
Previous experience or education in Equity, Diversity and Inclusion and/or Indigenous Cultural Awareness, an asset
Previous experience in a Home or Community care setting, preferred

Responsibilities

Provide psychosocial assessment, counselling/psychotherapy, case management, Patient/family education, supportive care, discharge planning, service coordination and consultation.
Assist the client in achieving optimum recovery and quality of life.
Support Sr. Manager - ICCP in the efficient and effective operations of the program activities.
Provide leadership in high-risk social situations, program development, advocacy and developing and maintaining strong community linkages.
Participate in mentoring community development, teaching, continuous quality improvement and research activities.
Maintain current working knowledge of relevant legislation in Mental Health Act, Health Care Consent Act, Substitute Decisions Act, Public Hospitals Act, Long Term Care Act, Child and Family Services Act, PHIPA and Excellent Care for All Act.
Maintain expertise in generic social work practice and implements evidence-based practice which includes family/individual and group treatment modalities, case management, crisis intervention and discharge planning.
Document all patient related interventions adhering to the OCSWSSW Standards of Practice and the RSW disciple-specific documentation guidelines.
Complete virtual care visits as per client care plans require.
Conduct comprehensive psychosocial assessments from a systems perspective which will include contact information (POA, SDM, NOK), current family/social status, financial situation, community agency involvement, mental health status, psychosocial history, social work analysis, identified issues goals and intervention plans.
Identify and intervene with high-risk social work analysis, identified issues, goal and intervention plans.
Identify and intervene with high-risk social situations such as intimate Partner Violence, Child Abuse/Neglect, Elder Abuse/Neglect, Financial Abuse, and others as appropriate utilizing best practise social work guidelines.
Provide theory-based counselling which may include crisis intervention and illness adjustment counselling.
Provide case management for an assigned client area including the facilitation of client and team goals related to function and discharge, connecting the client and/or family with services and/or resources in the community and ensuring patients and families understand the plan of care post discharge.
Coordinate all complex discharges and facilitates program specific case management activities.
Assume the lead responsibility for discharge planning including the identification of client and family needs and resources related to safe patient discharges.
Provide mentorship around specific developed areas of expertise to new RSW staff and healthcare providers of other disciplines.
Meet the requirements of Ontario Social Work re-certification through continuing education as outlined by the OCSWSSW.
Comply with all required Workload Measurements and other statistical data collection expectations.
Engage in knowledgeable, sensitive and expert care of seniors, and support of their families.
Advocate in the best interests of the clients.
Complete regular, mandatory and optional professional development.
Engage in self reflection and adaptation to the changing needs of clients.
Work with others in ordering of required supplies and/or equipment.
Record treatment activities in client charts, maintaining on-going support of other interdisciplinary program staff.
Develop and present reports and/or metrics as requested.
Support clients in setting up therapy appointments.
Support referral/intake processes of the program.
Provide general assistants to program Managers.
Perform general administrative duties related to the role.
Participate on committees and program development related to areas of practice.