Social Worker - Extensivist Clinic

at  Southlake Regional Health Centre

COMPANY BIO

Southlake is building healthy communities through outstanding care, innovative partnerships, and amazing people. We deliver a wide range of healthcare services to the communities of northern York Region and southern Simcoe County. Our advanced regional programs include Cancer Care and Cardiac Care and serve a broader population across the northern GTA and into Simcoe-Muskoka.
Our team of nearly 6,000 staff, physicians, volunteers, students and Patient and Family Advisors are committed to creating an environment where the best experiences happen. As a recognition of our commitment to quality and patient safety, we have received the highest distinction of Exemplary Standing from Accreditation Canada.

JOB SUMMARY

Join Southlake’s New Extensivist Clinic Team – A Transformative Approach to Outpatient Care!
Southlake is excited to announce new opportunities in our innovative Extensivist Clinic, opening in early 2025. A first-of-its-kind, intensive outpatient care program designed to deliver leading-edge, patient-centered care. This Clinic is a collaboration of a dedicated inter-disciplinary team, including Nurse Practitioners, RNs, RPNs, Social Workers, Pharmacists, and others, to ensure comprehensive patient care.
The Extensivist Clinic will provide integrated care for patients to prevent unnecessary admissions and ensure safe, earlier discharges with coordinated follow-up. It provides a broader approach to sustaining patient health and stability over time.
Building on lessons learned from the successful Southlake@home program which has now spread across the province, this Clinic serves as a critical bridge between inpatient and outpatient care and community services. It offers stabilization and ongoing follow-up for patients Located on our hospital campus in Newmarket, the Clinic takes advantage of Southlake’s robust resources and expertise to enhance patient outcomes.
Open 7 days a week, the Extensivist Clinic is committed to providing continuous and accessible care for patients.
Be a part of our exciting future, apply today!
Job Summary:
The Social Worker Care Manager coordinates and delivers comprehensive mental health and addiction services, working collaboratively with patients, families, and the inter-professional care team to provide holistic and patient-centered care. They conduct in-depth psychosocial assessments and provide interventions, including resource education, emotional support, counseling, case management, and advocacy, to optimize patient well-being. Additionally, the Social Worker Care Manager develops and coordinates comprehensive discharge plans for complex patients, ensuring smooth transitions and continuity of care within the community.

QUALIFICATIONS

• Masters’ Degree in Social Work from an accredited university required.
• Member in good standing with the Ontario College of Social Workers and Social Service Workers (OCSWSSW), with no terms, conditions, or limitations required.
• Minimum three years relevant social work /discharge planning experience within an acute care setting preferred.
• Demonstrated ability to provide the provision of assessments and treatment planning, conflict resolution and problem solving for both inpatients and outpatients.
• Working knowledge of legislative acts to include, but not limited to: Mental Health Act, Long Term Care Homes Act, Retirement Homes Act, Child Youth and Family Services Act, Health Care Consent Act, Substitute Decisions
• Working knowledge and experience with transitions in care planning, relevant community resources and system navigation.
• Demonstrated knowledge and skills in psychosocial assessment, conflict resolution, and creative problem-solving.
• Demonstrates capacity to work co-operatively and constructively with other team members and develop effective partnerships with community agencies.
• Demonstrated strong communication and interpersonal skills, with the ability to work. collaboratively with patients/families, inter-professional team members, and other stakeholders
• Demonstrated excellent organizational and coordination skills and the ability to prioritize multiple competing workload demands.
• Demonstrated excellent written and verbal communications skills.
• Demonstrated flexibility and ability to work under pressure in a fast paced environment.
• Demonstrates flexibility to meet additional responsibilities as program demands.
• Demonstrated understanding and complies with patient and staff safety policies and procedures that foster a safe and inclusive environment for all.
• Demonstrated commitment to providing an exceptional experience for staff and caregivers within a challenging and exciting health care environment.
• Models behaviour that is aligned with the values of Southlake Regional Health Center
   Always with compassion
   Power of many
   Serve with purpose
   Every voice matters
   Courage to think differently

• Functions as a member of the inter-professional team to coordinate complex discharge plans; provide linkages to community resources and to support patients, families and caregivers to transition through the continuum of care.
• Functions as a member of an inter-professional team to coordinate complex discharge plans
• Provides comprehensive and coordinated psychosocial assessments.
• Facilitates and participates in appropriate patient care planning in daily bullet rounds and case conferences.
• Assists the patient, family and caregiver to better understand the impact of their illness/disability.
• Provides short term crisis and grief counselling for patients, families and caregivers.
• Provides information and education to patients, families and caregivers pertaining to their plan of care including discharge.
• Maintains relevant documentation of social work services as per the Ontario College of Social Workers and Social Service Workers (OCSWSSW) standards available on the link included: https://www.ocswssw.org/professional-practice/code-of-ethics/
• Holds primary responsibility for complex discharge planning across programs.
• Utilizes all systems, policies and processes to facilitate sustainable and durable discharges (i.e., iplan, PODS, RM&R, care pathways, etc.)
• Actively works with the clinic manager and RN Care manager. .
• Identifies disposition challenges to the Unit Manager and works in a collaborative and interdisciplinary manner with all team members within the hospital and across the care continuum, including the home care and other community supports.
• Links patients with appropriate community supports/services as required for ongoing follow up intervention on transition from hospital to community.