Social Worker, Geriatric Navigator

St. Joseph's Health Centre, Toronto; Toronto; On-site; CAD 65,000 - 90,000; Full time

Job summary

St. Joseph’s Health Centre, Toronto is seeking a licensed Social Worker to join the Medicine Program, focusing on geriatric and general internal medicine care.

You will assess, coordinate and provide services to geriatric clients and families, including crisis intervention and short-term management, to reduce ED readmissions and LTC admissions. You will collaborate with the Geriatric Medicine consultation team and SCOPE navigator, develop follow-up plans, and connect clients to community

Qualifications

• Must be licensed in good standing with the Ontario College of Social Workers and Social Service Workers.
• Master’s Degree in Social Work is required.
• Minimum of 2 years’ experience with geriatric populations.
• Access to a vehicle is required.
• Current BLS (or willingness to complete within probationary period).
• Excellent communication, critical thinking and interpersonal skills.
• Experience with virtual care is an asset.

Responsibilities

• Coordinate and support post-discharge care of geriatric patients with discharge planner and general medicine team.
• Case conference with other providers involved in patient’s care as appropriate.
• Develop short-term follow-up plan for high-risk readmission patients.
• Develop appropriate recommendations and make community referrals (e.g., CHCs, geriatric outreach teams).
• Coordinate services with Community Health Centre in patient’s postal code and liaise with Geriatric Outreach team.
• Collaborate with SJHC’s SCOPE navigator to support family physicians with timely advice from the Geriatric Medicine Team.
• Develop, monitor and track key performance indicators and quality metrics with Medicine Program leadership.
• Obtain information to assess, analyze, plan, implement and evaluate a plan of care.
• Ability to learn to complete comprehensive geriatric assessments.
• Maintain safety for patients, families and colleagues.
• Familiarity with Health Profession Act, Mental Health Act, Health Care Consent Act and Substitute Decisions Act.

Skills

Communication

Critical thinking

Interpersonal skills

Time management

Organizational skills

Advocacy

Flexibility

Problem solving

Cultural competence

Education

Master's Degree in Social Work

Licensed by Ontario College of Social Workers and Social Service Workers (OCSWSSW)

Job description

This position will function as a member of the Medicine Program, including Geriatrics and General Internal Medicine working collaboratively with the Geriatric Medicine consultation team at St. Joseph’s Health Centre (SJHC). The role of the social worker is to provide assessment, coordination and provision of services to geriatric clients/families including crises intervention and short-term management. To help with reducing emergency department (ED) readmissions and admission to Long Term Care (LTC). The Navigator, in collaboration with the inter-professional treatment team in hospital, the social worker will provide short term follow-up to clients of the program to maintain clients at their highest level of functioning in the community.

Major Responsibilities

• Coordinate and support post-discharge care of geriatric patients in collaboration with discharge planner and general medicine team;
• Case conference with other providers involved in patient’s care as appropriate;
• Develop short term follow up plan for high risk readmission patients;
• Ability to develop appropriate recommendations, and make appropriate community referrals as necessary (such as community health centres, geriatric outreach teams);
• Facilitate co-ordination of services with community Health Centre (CHC) in patient’s postal code. Liaise and link with community Geriatric Outreach team as appropriate;
• Work collaboratively with SJHC's Seamless Care Optimizing the Patient Experience (SCOPE) navigator to address gaps to support family physicians to get timely and if needed urgent advice from SJHC's Geriatric Medicine Team;
• Develop, monitor and track key performance indicators and quality improvement metrics in consultation with the Medicine Program leadership;
• Obtains all relevant information to assess, analyze, plan, implement and evaluate a plan of care/action to coordinate client needs;
• Ability to and or willing to learn how to complete comprehensive geriatric assessments;
• Practice in a manner that prioritizes safety, including the safety of oneself, patients, families, and colleagues;
• Working knowledge of the regulated Health Profession act, mental health act, health care consent act and substitute decision act.

Qualifications

• Must be currently licensed by and in good standing with the Ontario College of Social Workers and Social Service Workers (OCSWSSW) for practice in all applicable clinical areas
• Must hold a Masters Degree in Social Work
• Current BLS (or willingness to complete within probationary period)
• Minimum of 2 years experience in working in a geriatric population;
• Experience working in the community service is preferred;
• Expertise in caring for vulnerable patients with multiple-comorbidities would be preferred;
• Experience with virtual care would be an asset;
• Access to a vehicle required.
• Excellent communication, critical thinking, and interpersonal skills
• Proven flexibility and adaptability in a fast-paced environment
• Excellent time management, organizational and prioritization skills as relates to patient care
• Demonstrated advocacy, commitment to and involvement with profession preferred (e.g. involvement with professional association, representation on relevant committees)

Potential candidates who do not meet all preferred qualifications are still encouraged to apply.

Unity Health Toronto is committed to creating an accessible and inclusive organization. We strive to provide a recruitment process that is barrier-free and in compliance with the Accessibility for Ontarians with Disabilities Act (AODA) and the Ontario Human Rights Code. We understand that you may require an accommodation at any stage of the recruitment process. When you are contacted, please inform the Talent Acquisition Specialist and we will work with you to meet your accommodation needs. We want to emphasize that all accommodation requests are handled with the utmost confidentiality, respecting your privacy and dignity.