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 community Team social worker
Hours of Work: 35 hours per week
Reports to : Director, Community
Date Posted: December 1,2021
Position open till 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 behaviors, 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)
Complete clinical triage for new referrals
Gather and record data within all domains of Comprehensive Geriatric Assessment (CGA)
Responsible for the identification of patient/family goals and coordinated care planning
Conduct interview with patient and family, utilizing strength-based and person-centred approach
Implement care plans, in collaboration with patient and caregiver/s, to maximize independence at the highest level possible
2. Provides patient and family-centered case management
Conduct assessments, prepare person-centered/goal-oriented care plans, and provide case management for patients, as part of the GAIN Community Team
Provide crisis management, counseling and follow-up plans, as required, including liaising with the patient’s family/caregiver and/or other care providers
Co-ordinate and monitor self-directed patient caseloads with the inter-professional team
Identify, document occurrences, and take corrective actions, when required
Plan, organize, and facilitate case conference meetings with team
Work with patient and caregivers on individual, couple and family issues; and liaises with community partners including primary and community care providers
Provide ongoing case management and support to families, caregivers and patients to improve and/or maintain function
Maintain accurate records in care plans, progress notes, and statistical reports, as required
Participate in regular meetings with the Director of Care Services and the inter-professional team to assist in program development and ongoing monitoring and evaluation
3. System navigation, information and referrals Focus on supporting patients to manage transitions, whether between GAIN’s own services or across multiple service providers
Enhance system navigation, care coordination and transition support for patients to/with the most appropriate provider/s, setting/s, and type/s of interventions
Participate 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)
Refer 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
Skills & Experience:
• 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
Vulnerable Sector Check required
A valid driver’s license and a car is required for home visits
Proof of full COVID-19 vaccination for required
Senior Persons Living Connected is a diverse work environment. We encourage applications from all persons, including persons with disabilities. Accommodation will be provided, if needed, in accordance with the Ontario Human Rights Code and Accessibility for Ontarians Disability Act.