Social Worker

11 hours ago


Hamilton, Ontario, Canada Hamilton Family Health Team Full time
About the Role

We are seeking a highly skilled Social Worker to join our Interprofessional Primary Care team at the Hamilton Family Health Team. This innovative role will provide clinical support to unaffiliated physicians and their patients, as part of an interprofessional team focused on systems and environmental factors impacting patients' health.

Key Responsibilities
  • Perform biopsychosocial assessments and develop treatment plans in collaboration with patients, primary care providers, and the interprofessional team.
  • Provide short-term treatment, evaluation, and resource referrals as needed.
  • Monitor and adapt treatment plans collaboratively with patients and the interprofessional team.
  • Participate in the development and execution of health promotion activities to increase outreach and patient enrollment.
  • Assist patients and providers in navigating the health and community service systems to identify and connect them with appropriate services and supports.
  • Participate in team building, program development, and quality improvement activities.
  • Advocate with patients and their families in matters affecting health.
  • Liaise and build relationships with other primary care providers and community agencies as required.
  • Teach family medicine residents and medical and allied health students about the role of the social worker and psychosocial issues facing patients and families.
  • Provide communication to hospital and community staff and other interprofessional team members to ensure continuity of care.
  • Support patients in achieving goals and improving functioning in community integration, health and wellness, employment, financial literacy, personal care, household management, housing, and food security.
  • Provide evidence-informed mental health interventions with patients and families.
  • Develop and facilitate evidence-informed treatment groups and patient education groups collaboratively with the interprofessional team and clinical leadership.
  • Community connection, outreach, and partnership building.
  • Co-design processes to attach new unaffiliated physicians and their patients to these services.
  • Collect data as required for statistical/reporting purposes.
  • Provide informative reports as directed and requested by the Manager, Primary Healthcare or Professional Practice Lead.
  • Participate in staff meetings and ongoing professional development opportunities as required.
  • When required, assist in developing and implementing the clinical model and guidelines for collaborative care.
  • Outreach to the community.
  • Understanding the needs of the broader community and the HFHT patients.
  • Group facilitation (virtual and in-person).
  • Group evaluation.
Why Join Us?

The Hamilton Family Health Team offers a competitive employee value proposition, including a multi-sector pension plan, extended health care benefits, and a flexible work schedule. We are committed to building a respectful, caring, equitable, and inclusive workplace where staff reflect the diversity of the communities we serve.


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