Outreach Worker

2 days ago

Kitchener, Canada Centre for Family Medicine FHT Full time

The Centre for Family Medicine is currently seeking a full-time Outreach worker to join the In-Home Healthcare and Outreach Team; and support the CFFM Refugee Health Clinic **for a one-year maternity contract.**

The Centre for Family Medicine has many community-based primary care programs, two of which are, the In-Home Healthcare and Outreach Team (In-Home Team) and Refugee Health Clinic (RHC).

**In-Health Team - Background**

The In-Home Team is an inter-professional team that delivers in-home primary care to complex patients in the Kitchener-Waterloo-Wellesley-Wilmot-Woolwich (KW4) area, including those who:

- have complex chronic conditions
- are living with mental health, psychosocial and/or addictions challenges
- are very frail or have frequent falls
- are not managing well, or are not getting the care and support they need
- are visiting the ER or being hospitalized frequently
- cannot get to regular office appointments for whatever reason

This team currently consists of a nurse practitioner, two outreach workers, a social worker, a chiropractor/mobility specialist, a pharmacist, a registered practical nurse, and a team-assistant. While the team is primarily an in-home team, it also provides support to other CFFM efforts, and works collaboratively with community partners including supporting clinics operating in several community locations. Staff of the In-Home Team approach situations from a client-based perspective, while working to building and strengthen client relationships with the healthcare system.

**RHC - Background**

RHC is designed as a short-term transitional interdisciplinary clinic supporting Government Assisted Refugees who have been destined to Waterloo Region. Within this clinic, the Outreach Worker will work closely with the primary care team to support via a lens of social determinants of health.

The RHC is a team of health care professionals who work collaboratively with Reception House to support the arrival of newcomers into our Region by providing access to healthcare in a timely and dignified manner. RHC is patient and family centric, welcoming and inclusive, and creates an environment that provides care in a respectful and culturally sensitive way. RHC has mastered a team-based approach and continues to collaborate with community partnership.
- This role, supporting two unique programs, is an extremely rewarding opportunity that supports some of the most complex and vulnerable populations in Waterloo Region. If you feel these approaches to delivering care align with your personal mission, vision and values, this might be an opportunity for you_

**Position Overview**

The Outreach Worker is a key CFFM position whose role is to support care delivered to patients in their homes and in clinic with a strong emphasis on social determinants of health. This may include case management, system navigation, visiting patients, developing and supporting the implementation of care plans, and accompanying patients to appointments. The Outreach Worker requires initiative and passion in caring for our patient populations. The role and responsibilities will evolve and develop over time.

**Responsibilities**

**_ Team Participation_**
- Works as both a lead and case management support to other team members working with specific patients
- Participates in discussions, gap-analyses, problem solving, and decision-making at weekly Team meetings
- Ensures that the Team and other stakeholders are kept informed about developments and new and existing patient challenges as necessary
- Consults with other team members who have different or enhanced areas of expertise

**_ Patient Care _**
- Listens to patients to identify their social, physical and emotional needs
- Builds on existing resources and connects patients to additional resources to create a support network
- Advocates for services as necessary
- Visits patients on behalf of other team members and accompanies patients to appointments (for example specialists, community services etc.)
- Negotiates with other care providers about how service is provided to ensure patient participation in their own care
- Follows all safety protocols while working with residents in their home and community

**_ Documentation and Records Management_**
- Documents and maintains clear records in EMRs
- Provides clear and timely communication with other healthcare and social service providers
- Other correspondence as required

**Qualifications and Experience**:

- Bachelors or Master degree in social work, social service work, education or any other health profession i.e., BSW, MSW, SSW etc.
- 3 years of experience, preferably working with complex patients (medically and socially)
- Demonstrated experience in social determinants of health
- Preferred experience or education in community or primary health care and an adult specialty
- Demonstrated ability to work collaboratively with Allied Health Professionals
- Experience working with non-English speaking

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