Social Worker, Community Health

INTRODUCTION

As part of the Primary Care Team, the Social Worker provides essential wholistic support to patients through case management, health promotion and patient advocacy to address the social, emotional, financial and spiritual factors that impact their health. They act as a vital member of the interdisciplinary team, bridging the gap between a patient’s medical needs and their broader life circumstances.

• Assess patient needs
• Provide referrals to community resources and services
• Provide emotional support, understanding and encouragement related to treatment decisions and diagnosis
• Provide supportive counselling as required
• Develop and lead health promotion activities
• Liaise with other departments within the organization, external community agencies and service providers
• Develop and deliver education to individuals, families and communities
• Perform community health needs assessments and participate in community health planning
• Advocate on behalf of patients, families, groups and communities as needed
• Provide case management support for patients accessing primary care
• Support complex discharge or transition planning
• Follow up on referrals, screening and adherence to follow-up care and health care provider recommendations
• Coordinate social services and complex referrals to facilitate information exchange
• Attend and participate in client conferences and complex case resolution with the interdisciplinary team
• Facilitate meetings with care team members, clients and families when needed
• Develop patient resources as required
• Provide all care from a patient centered, trauma informed approach
• Strong interprofessional communication

• Bachelors or Masters degree in Social Work
• Must be active and currently registered with the Ontario College of Social Workers and Social Service Workers
• Experience working with the Indigenous community
• Experience working in Primary Care or part of an Interdisciplinary Team Excellent interpersonal skills
• Excellent communication skills, written, oral and