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Community Care Social Worker

2 months ago


Burnaby, British Columbia, Canada Fraser Health Full time
Job Summary

We are seeking a highly skilled and compassionate Community Care Social Worker to join our team at Fraser Health. As a Geriatric Care Specialist, you will play a vital role in providing care management to frail older adults with complex, acute, and chronic conditions.

Key Responsibilities
  • Establish and maintain collaborative partnerships with clients, families, primary care practitioners, home health professionals, and other community partners to optimize client capabilities and community engagement.
  • Provide clinical assessments, coaching, interventions, services, and follow-up to enable clients and their families to live confidently and safely at home.
  • Emphasize the promotion, maintenance, and restoration of health, including the treatment of diseases through teaching, counseling, and direct client care.
  • Facilitate and manage client transitions across the healthcare continuum to optimize recovery from or adapting to changes in the client's condition.
  • Establish a therapeutic relationship with clients through the use of interpersonal and interviewing techniques to ensure client choice and autonomy in decision-making and care planning.
  • Collaborate with clients and families to conduct and document individualized client assessments and develop care plans that reflect client goals and priorities.
  • Provide direct client care and identify other care services required in accordance with applicable guidelines, policies, and evidence-based best practices.
  • Initiate and evaluate the appropriateness and effectiveness of short- and long-term care plans to meet specific client goals.
  • Develop next steps in collaboration with clients and families and support a transition process for achieving client care goals across the care continuum.
  • Access system information and resources to review client data and incorporate findings into care plans.
  • Plan, organize, and establish priorities using resources effectively and efficiently.
  • Respond to unanticipated events and changing client or service assignment needs.
  • Document assessments, care provision, and client responses according to professional standards and established guidelines.
  • Prepare reports in accordance with established standards and procedures.
  • Provide health education to clients, families, and caregivers to increase their knowledge regarding client health and promote/enhance client health status.
  • Develop relevant informational materials and participate in staff education programs.
  • Collaborate with members of the multidisciplinary team to ensure effective and consistent client care planning and delivery.
  • Advocate for system/program changes that will enhance the capacity to support clients and families.
  • Participate in the development, implementation, and evaluation of quality improvement initiatives within the program.
Qualifications
  • Bachelor's degree in Social Work from an approved school of Social Work.
  • Two years' recent, related clinical experience working with complex geriatric clients and/or adults with chronic illnesses in a community health setting.
  • Current full registration with the BC College of Social Workers.
  • Valid BC Driver's license and access to a personal vehicle for business-related purposes.
Skills and Abilities
  • Demonstrated knowledge, skills, and competence in the areas of gerontology, geriatrics, and adults living with chronic illnesses.
  • Demonstrated ability to complete initial and ongoing client assessments and provide care through therapeutic interventions.
  • Demonstrated ability to communicate effectively, both verbally and in writing.
  • Knowledge of chronic disease management models.
  • Demonstrated ability to integrate and evaluate pertinent data from multiple sources to problem-solve effectively.
  • Knowledge of broad healthcare services, community resources, agencies, and their role in providing a continuum of care.
  • Ability to promote client-focused care, including sensitivity to diverse cultures and preferences.
  • Ability to independently manage and prioritize a caseload of diverse clients.
  • Ability to teach clients and others about topics essential to healthcare, health promotion, and care self-management using care management principles.
  • Demonstrated ability to mentor and act as a preceptor to staff.
  • Ability to work effectively in a dynamic environment with changing priorities.
  • Ability to work independently and as a member of an interdisciplinary team.
  • Ability to operate related equipment, including applicable software applications.