Social Worker, Extended Health Team & Coordinated Attachment

Calgary Foothills Primary Care Network•Calgary, AB

just now•Hybrid

About The Position

Calgary Foothills Primary Care Network (PCN) is a collaborative group of healthcare professionals dedicated to providing optimal primary care in northwest Calgary and Cochrane. The PCN fosters a team environment that encourages initiative, creativity, and participation in decision-making. The Extended Health Team (EHT) within the PCN includes a multidisciplinary group of professionals who assist patients with complex chronic health conditions and psychosocial challenges to self-manage their conditions, achieve goals, and access support. Coordinated Attachment is a specialized program offering transitional medical home services for complex patients facing psychosocial issues or chronic disease management challenges, supported by a Primary Care Provider and an allied health team. The Social Worker, reporting to the Program Manager, plays a crucial role in supporting both the EHT and Coordinated Attachment programs by collaborating with physicians, PCN teams, and community partners to deliver patient-centered care for individuals with chronic diseases or complex health conditions.

Requirements

Strong awareness of community resources and referral processes
Expertise in active listening and motivational interviewing
Experience as a case manager
Excellent communication (written and verbal), organization and critical thinking skills
Strong skills in collaborating with team members and physicians
Maintains an individual’s dignity and self-worth during all interactions
Excellent group facilitation skills
Ability to provide evidence-based care
Ability to work well in a team setting and independently
Excellent computer skills are required
Strong awareness of health assessment and documentation skills
Ability to prioritize, manage time effectively and be flexible in a very dynamic work environment
Ability to work flexible hours, including evenings/weekends, when required
Accepts, implements and evaluates change with a positive attitude
Bachelor’s Degree in Social Work
Registered with Alberta College of Social Workers
Must possess a valid driver’s license and have access to a reliable vehicle
Completion of a satisfactory criminal record check and/or Vulnerable Sector Search.

Nice To Haves

Experience with trauma informed care an asset
MoCA certification required

Responsibilities

Connecting patients and their families to identified resources that address their immediate needs and then assists them to be self-reliant in the future
Liaising and advocating with appropriate government and community agencies in conjunction with the patient, including completing referrals
Conducting cognitive assessments using a team-based approach, which may include cognitive screening of patient and/or collateral history gathering
Working with patients on self-management by providing coaching and education to help advance their skills, knowledge and self-efficacy in adopting healthy lifestyle behaviours that are meaningful to them
Helping to build care plans with patients who have, or are at risk of, chronic health conditions through biopsychosocial health assessment, collaborative goal setting, applicable interventions based on patient readiness, regular follow-up and evaluation of progress and case management throughout the patient’s participation in the program
Supporting navigation of the health care system to connect patients and the medical home to applicable PCN, community and health system resources as needed
Promoting continuity of patient care through effective written and verbal communication with the Patient’s Medical Home and those involved in the circle of care
Building relationships and developing the Social Worker role within and outside of the PCN team
Providing care through individual and facilitated group appointments, which may include home visits
Consulting with hospital, community and other PCN health care providers to ensure seamless care transitions
Participating in development, delivery, evaluation and quality improvement of health programs and evidence-based practice
Collecting and maintaining data for service indicators, progress reports and evaluations
Adheres to and performs activities and care within the full scope of practice as defined under the Health Professions Act