With a passion for care towards residents, families and team members, the Social Worker is accountable for providing outstanding care and support to residents, families, staff and volunteers within their designated scope of practice. The Social Worker demonstrates responsiveness to the holistic needs of residents by advocating, promoting choices, maintaining dignity and facilitating independence.
Promotes service excellence through active participation with the Interdisciplinary Team to achieve and maintain quality resident centered care within the scope of Social Work.
Assesses psychosocial functioning to enhance resident choice and coping as related to issues such as, adjustment to illness, placement, loss and grief, etc.
Completes a standardized and individualized psychosocial assessment outlining the identified needs/concerns, goals, interventions for counselling, consultation or resource assistance required prior to admission conference and modifies intervention plans to meet the resident’s goals when there is change in status
Provides consultation, guidance, and education to ID team members to promote understanding of the needs and circumstances of each resident, gained from assessment, for the purposes of care planning.
Assesses resident and family preparedness for discharge planning: resources required and supports needed.
Provides a range of individualized person-centered interventions consistent with ACSW Standards of Practice to residents, families/caregivers, colleagues, and systems, including but not limited to grief and loss, resource navigation, peer support, group facilitation, program development, counselling, conflict resolution, etc.
Facilitates therapeutic or mutual support groups for residents and/or caregivers.
Provides social work consultation in review of programs, policies and procedures and actively participates in the implementation and evaluation of new programs and services.
Maintains current knowledge of community services/resources and updated records of relevant materials and assesses resident and family needs for community services/resources to assist with the psychosocial and instrumental needs.
Educates and provides accurate and updated community resource information to clients.
Assumes a leadership role in coordinating resident and family referrals to appropriate government/community agencies (e.g. OPG, OPT, AISH, ASB, OAS) to assist in meeting resident financial needs.
Advocates for resident and family by consulting and collaborating with community services (e.g. GMHCS, Continuing Connections Mental Health Program, Transition/Home Care services)
Provides follow up services to residents and family members after discharge, as appropriate.
Accurate, comprehensive, and timely documentation of resident care assessment, interventions, and outcomes in alignment with Bethany policies and procedures.
Documents in healthcare records, including contributing to resident centered care plan.
Collects information from resident, family and collateral information sources for the purpose of gathering psychosocial information (social background, family dynamics, values etc.)
Ensures record of resident participation is completed and monitored.
Communicates resident changes and unusual occurrences as appropriate.
Assesses legal documentation to ensure appropriate documentation is in place (EPOA, PD, Guardianship and Trusteeship).
Provides information and assistance to residents and families in preparing legal documentation. Where necessary, completes applications for referral to the Office of the Public Guardian and Public Trustee.
Assesses financial status of residents to ensure resident receives appropriate financial assistance from government/community resources. Where necessary, assists residents’ with applications for financial benefits.
Completes required reports and forms in a timely manner, including monthly statistical records reflecting social work activities.
Facilitates Resident/Family Care conferences (Admission, Annual and Special Care Conferences) and participates in clinics, medical/ID team rounds, and other meetings related to resident care.
Cares for and actively participates and assists the Interdisciplinary Team to achieve and maintain a responsible atmosphere of resident centered care.
Promotes constructive caring relationships with the Interdisciplinary Team, by fostering an understanding of the unique contributions of all team members.
Educates and assists the Interdisciplinary Team to provide resident centered services.
Promotes and maintains a partnership with residents’ families.
Assists in the review and participates in the implementation and evaluation of programs and services.
Contributes to the establishment of short and long term goals for the resident.
Facilitates in the training of staff (e.g., Goals of Care Designations).
Promotes effective liaison with the government and community working in partnership to promote community awareness of social work and health issues as appropriate.
May be delegated to complete additional assessments and assist with onboarding processes (e.g., Tours, Admissions, ICP, etc.) as directed by the Care Services Manager or affiliate.
