Social Worker / Patient Navigator

Under indirect supervision, and working as part of an interdisciplinary team, the Social Worker/Patient Navigator provides high quality counseling and support to assigned patients, consistent with the philosophy of the City of Lakes Family Health Team. The Social Worker/Patient Navigator is responsible for helping individuals, couples, families, groups, and the community develop the skills and access the resources they need to enhance social functioning. Responsibilities include providing counselling, therapy, referral to other supportive social services, and health education to patients with a focus on health promotion, disease prevention, and chronic disease management.

In addition to direct patient support, the SW/PN will work in partnership with community and social service agencies as lead for the Patient Navigation and Income Security programs.   In this role, the SW/PN assesses the needs and gaps in service and assists in establishing best practice guidelines, build tools, identifies appropriate resources and provides support and ongoing follow-up to diverse, low-income patients and families.  

Key Areas of Responsibility and Duties

Mental Health Counselling

  • Provide assessment and treatment in collaboration with the client
  • Monitor patient goals and outcomes through ongoing assessment and documentation of treatment progress
  • Perform house calls and community outreach visits
  • Identify cases of child abuse or neglect and report accordingly
  • Participates in case presentations/reviews and discussion within the FHT
  • Present on various aspects of social work to FHT to assist them in their practices
  • Provides training and education to individuals, families, and the community on how working with physical, psychological and social health can guide the creation of prevention and intervention plans
  • Maintains clear, confidential and concise records
  • Participates in continuing education for professional growth and ensures skills are kept current, and disseminates pertinent knowledge to all staff

Patient Navigation

Develop the Patient Navigator program

  • Offer system navigation and support
  • Build and maintain a database of community and social services resources and facilitate pathways to appropriate community-based services and supports
  • Advocate to community and social service agencies on behalf of our patients
  • Liaises with external organizations, including community social support agencies, legal aid clinics, homeless support agencies, advocacy groups and agencies focused on vulnerable sub-populations to develop referral pathways and supports for patients
  • Bridge communication gaps between community agencies and the COLFHT providers

Facilitate patient access to income security services

  • Develop and implement strategies to address income security for patients
  • Assist low-income patients and families with income security-focused interventions
  • Plan programs of assistance for patients including referral to agencies that provide services to address income security
  • Advocate for access to financial assistance, legal aid, housing, social services
  • Develop the capacity of Family Health Team physicians and clinical providers to identify low-income patients and address income security
  • Develop and implement information self-help sessions such as banking basics, income tax submissions and social service forms for the targeted population

Evaluate the impact of Patient Navigation and Income Security programs

  • Assess the FHT's capacity to address income security as a health risk by developing a scorecard or measureable indicators
  • Enhance the capacity of the EMR to help providers & patients with system navigation
  • Collaborate with Quality Improvement staff to generate summaries of performance on metrics relevant to patient navigation and income security
  • Participate in evaluation data collection as needed

Qualifications

  • A bachelor’s degree in Social Work from an accredited university is required
  • Minimum of 3 years of related working experience
  • Must be a member in good standing with the Ontario College of Social Workers and Social Service Workers
  • Experienced in social work interventions and strategies to assist clients or families to achieve optimum psychosocial and social functioning
  • Working knowledge of the Mental Health Act, Healthcare Consent Act, Substitute Decisions Act and community mental health resources
  • Experience in providing one-on-one supports to individuals with diversity in income, education, ability, and mental health status
  • Excellent verbal and written communication. Listening, organizational, multi-tasking and problem-solving skills.
  • Demonstrated commitment to and knowledge of community-based resources
  • Demonstrable knowledge of financial matters affecting low-income people, including income security programs and policies, tax systems, access to financial services, and other income support programs such as WSIB and private insurance companies.
  • Previous experience brokering social support services between agencies
  • Experience in the development of educational materials for health providers and patients
  • Experience with data collection, research and quality improvement
  • Experience with a electronic medical records system is an asset
  • Demonstrated ability to work effectively in a multi-disciplinary team environment
  • Bilingual in French and English considered an asset