Primary & Community Care Social Worker

Fraser Health is responsible for the delivery of hospital and community-based health services from Burnaby to Fraser Canyon on the traditional, ancestral and unceded territories of the Coast Salish and Nlaka’pamux Nations, and is home to six Métis Chartered Communities.
Our team of nearly 45,000 staff, medical staff and volunteers is dedicated to serving our patients, families and communities to deliver on our vision: Better health, best in health care. Learn more .
Come work with us!
Fraser Health is proudly recognized as a BC Top Employer . Joining our team offers you opportunities to work in a rapidly growing organization with health professionals who are excellent in their respective fields, career growth and advancement, a competitive compensation package (including four weeks of vacation to start, comprehensive health benefits, and pension plan), and the rewarding opportunity to make a difference every single day in health care.
Effective October 26, 2021 all staff for all positions across health care in British Columbia are required to be fully vaccinated against COVID-19 (have received a full series of a World Health Organization “WHO” approved vaccine against infection by SARS-COV-2, or a combination of approved WHO vaccines). Please note this applies to all postings, and there are no exceptions.
Fraser Health values diversity in the work force and strives to maintain an environment of Respect, Caring and Trust. Fraser Health’s hiring practices aspire to ensure all individuals are treated in an inclusive, equitable, and culturally safe manner.
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Detailed Overview
Works within an interdisciplinary team to provide comprehensive services and therapeutic clinical counseling to clients and their families; conducts comprehensive social work and psychosocial assessments of clients and their families using a variety of assessment tools to provide treatment services for clients including liaising with community agencies and caregiver support groups; provides clinical support to the interdisciplinary team including physicians in the development of care plans and services within the assigned area of responsibility; participates on local committees and planning bodies to identify areas to improve the efficiency and effectiveness in service delivery to enhance client care services and reduce service gaps.
Responsibilities

• Facilitates timely exchange and provision of information regarding client care between the acute care facility and the community service to allow for individualized discharge planning; works with community service providers to ensure client care needs are met.
• Initiates, develops and carries out research activities and program planning and development relevant to the needs of the patient, families, hospital and community, as assigned.
• Partners with community services, health and social agencies including provincial Ministries, physicians and other primary care providers in the assessment and management of individuals at risk, making referrals to appropriate resources when longer term treatment or follow-up is required and exchanging relevant information.
• Collaborates with the interdisciplinary team in client care planning by interviewing the client and/or family to assess and determine care plan and type of service required; follows up and provides ongoing monitoring of complex psychosocial situations; evaluates client's response to interventions.
• Supports a seamless approach to care and service delivery across the healthcare system by participating in the admission and discharge process of clients in acute care and community; arranges meetings to assist in developing and coordinating comprehensive care plans and community services for clients; collaborates with the hospital and community services to determine the effective utilization of available resources.
• Maintains patient records by documenting assessments, charting information and preparing progress notes and reports in accordance with established standards, policies, procedures and current regulatory requirements.
• Participates on local committees and planning bodies to identifying opportunities for change, assess available resources, analyze outcomes and identify areas to enhance patient care services and reduce service gaps.
• Acts as a clinical resource for clients and their families by providing information regarding community resources and access to these resources, facilitating referrals where appropriate; determines if client is capable of making decisions around client care plans, in collaboration with the interdisciplinary team; refers client to appropriate health care professional for assistance and follows procedures around client incapacity, respecting the client's right to privacy and confidentiality.
• Conducts comprehensive social work and psychosocial assessments by interviewing the client and/or their family, obtaining relevant information, gathering social data and interpreting the data using a variety of tools, in accordance with professional standards, clinical policies, legislation and practices.
• Develops, coordinates and delivers in-services, presentations, psycho-educational and support groups and/or training by collaborating with members of the interdisciplinary team, determining relevant content, conducting literature searches, planning and coordinating seminars.
• Arranges and participates in joint home visits to clients and/or families with other healthcare professionals, as required; provides advice to the clients and/or caregiver about available community resources.
• Maintains a variety of records such as workload statistics by recording information into approved formats, collating data, analyzing trends, accounting for variances, preparing reports as required and provides recommendations to the Manager, Clinical Operations or designate, as required.
• Provides comprehensive therapeutic services by exploring the psychosocial response to identify problems, personal concerns, treatment objectives and facilitates change in coping style, behavior, attitude and feelings; participates with the client, families, community supports and the interdisciplinary team to coordinate services, manage cases and facilitates meetings.
• Performs other related duties, as assigned.

Qualifications
Education and Experience
Current full registration with the BC College of Social Workers.
Two (2) years' recent related experience in a complex health care environment such as a community or home health setting, or an equivalent combination of social work education, training and experience.
Valid BC Driver's License and access to personal vehicle for business-related purposes.
Skills And Abilities

• Demonstrated ability to conduct comprehensive social work and psychosocial assessment.
• Physical ability to carry out the duties of the position.
• Comprehensive knowledge of pertinent/relevant health care and privacy legislations.
• Demonstrated ability to communicate effectively both verbally and in writing.
• Comprehensive knowledge and understanding of counseling and clinical practice models as it related to individuals, families and groups.
• Demonstrated ability to organize and prioritize workload in a complex environment.
• Ability to operate related equipment including applicable software applications.
• Ability to educate and provide consultation to patients, families and healthcare professionals.
• Ability to effectively work independently and with others including working effectively in a multicultural environment, as part of an interdisciplinary team.
• Working knowledge of First Nations, Metis and Inuit health, culture and traditions.
• Comprehensive counseling skills including crisis counseling, brief therapeutic interventions and loss and grief applicable to patients, families and their support networks.