Gain Community Team Social Worker

**Mission Statement**: Understand the aspirations of seniors and respond with innovative supports.

**Vision Statement**: Building inclusive communities where all seniors are connected to living their best possible life.

**Position**:GAIN Social Worker

**Hours of Work**: 35 hours per week (Full Time; Permanent)

**Reports to**: GAIN Manager

**Deadline**:Until position is filled

**Position Summary**:
The Social Worker in Geriatric Assessment Intervention Network (GAIN) Community Team participates fully in the process of comprehensive geriatric assessment (CGA) and delivers community specialized geriatric services. Contributes to all aspects of the patient care including comprehensive assessment utilizing various standardized tools and clinical judgement. Also, completes specialized assessments to address issues related to mental health, elder abuse, substance misuse, significant caregiver stress, responsive behaviours, safety planning, and advanced care planning. Linkages to community resources and liaises with community partners, agencies, and other health professionals to optimize the health of patients and their capacity for autonomous living.

**Responsibilities**:
**1. Participate in inter-professional Comprehensive Geriatrics Assessment (CGA)***:

- Completes clinical triage for new referrals
- Gathers and records data within all domains of Comprehensive Geriatric Assessment (CGA)
- Responsible for the identification of patient/family goals and coordinated care planning
- Conducts interview with patient and family, utilizing strength-based and person-centred approach
- Implements care plans, in collaboration with patient and caregiver/s, to maximize independence at the highest level possible

**2. Provides patient and family-centred case management***:

- Conducts assessments, prepare person-centred/goal-oriented care plans, and provide case management for patients, as part of the GAIN Community Team
- Provides crisis management, counseling and follow-up plans, as required, including liaising with the patient’s family/caregiver and/or other care providers
- Co-ordinates and monitors self-directed patient caseloads with the inter-professional team
- Identifies, document occurrences, and take corrective actions, when required
- Plans, organizes, and facilitates case conference meetings with team
- Works with patient and caregivers on individual, couple and family issues; and liaises with community partners including primary and community care providers
- Provides ongoing case management and support to families, caregivers and patients to improve and/or maintain function

**3. System navigation, information and referrals***:

- Focuses on supporting patients to manage transitions, whether between GAIN’s own services or across multiple service providers
- Enhances system navigation, care coordination and transition support for patients to/with the most appropriate provider/s, setting/s, and type/s of interventions
- Participates in the prevention of adverse outcomes through environment optimizing, and provide support to assist in minimizing the risk of traumatic and adverse events (medically and psychosocially)
- Refers to Seniors Persons Living Connected or external support groups to enhance the adjustment of patients/caregivers

**Education**:

- Master’s Degree in Social Work required
- Membership in good standing with a regulatory body in Ontario - Ontario College of Social Workers and Social Service Workers (OCSWSSW) required
- Certificate/s in counselling an asset
- Valid First Aid and CPR certificate an asset

**Experience & Skills**:

- Two to three (2-3) years’ experience working with an inter-professional team in a healthcare setting
- Experience working with older adult population and knowledge of geriatric conditions
- Extensive knowledge on how to effectively serve an increasingly aging population with complex medical, functional, cognitive, and psychosocial needs
- Knowledge of assessment, counseling, and case management
- Sound understanding of community resources (social, legal, health and financial)
- Good assessment skills for evaluating dementias, cognitive impairments, depressions, and deliriums, mental health and addictions
- Sensitive to the cultural needs of patients from various ethnic groups
- Excellent interpersonal, communication, decision-making and assessment skills
- Ability to work independently and co-operatively in a busy multi-disciplinary situation
- Experience in conducting home visits for patient care an asset
- Fluency in a second language an asset

**Other***:

- Criminal Reference Check required
- A valid Ontario driver’s license and a car is required for home visits
- Proof of full COVID-19 Vaccination or Medical Exemption Certificate required

**While we thank all applicants for their interest, only those applicants selected for interview will be contacted.***: