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Social Worker, Don Mills Family Health Team

Toronto, Ontario
Deadline: June 23, 2011

Don Mills Family Health Team

Position:  Social Worker

Reporting to:  Executive Director &  Lead Physician (for clinical responsibilities)
Part time:   One day per week
Contact Info:

Position Overview

The Don Mills Family Health Team (DMFHT) provides primary health care, including health promotion and disease prevention and chronic disease management to the population of DMFHT catchment’s area.  The FHT is comprised of an interdisciplinary team of health care professionals who work in a collaborative model of care.  

The Social Worker (SW) will play an integral role in the care of the patients of the Don Mills Family Health Team. The Social Worker will assist the FHT in achieving its vision and mission. The role of the Social Worker in the Don Mills Family Health Team requires a thorough knowledge of mental health issues in a primary care context and the ability to function effectively in a team environment with physicians, other interdisciplinary health professionals and administrative staff. The role also requires thorough knowledge and understanding of community services and a high level of interpersonal skills to deal with patients and their families in a holistic compassionate fashion.


• Work collaboratively with other team members to manage the needs of patients of the DMFHT
• Accept all patients referred by the FHT physicians, triage referrals and assign priority ratings.
• Identify, analyze and provide appropriate treatment and/or referral for patients’ mental and psychosocial health care problems.
• Assist patients and providers to navigate the health and community service systems to identify and connect with appropriate services and supports
• Case management, including links to community services in such areas as assistance with daily living, crisis intervention, health promotion and prevention.
• Support patients to manage their clinical plans including medication, appointments, healthy choices and lifestyle
• Support patients to achieve goals in such areas as community integration, health and wellness, employment, personal care, household management, housing support
• Develop, update and maintain education resources for patients and for providers.
• Evaluate and document outcomes of individual patient care in collaboration with the team.
• Provide timely and informative reports as directed and requested by the Executive Director and/or Physician Lead.
• Observe, collect and record patient data in the EMR system.
• Participate in staff meetings, to exchange ideas, receive mutual support and monitor program outcomes as well as present case studies.
• Assist in the development and implementation of the clinical model and guidelines for collaborative care when required,
• Comply with established personnel policies, procedures, standards and guidelines for operation.
• Identify gaps and needed modifications in services.
• Facilitate referrals to other services as well as communication and networking between the primary care practice and hospital or home care.
• Maintain relations with networks, related professional organizations and other related service providers.
• Participate in building creative supportive environments for FHT staff and for patients
• Represent the mission, values and philosophy of the FHT in the community, including networks, meetings or presentations, as requested.
• Assist in the training and supervision of students and/or volunteers as requested by the Executive Director and/or Lead Physician
• Help patients to identify and use health resources
• Support patients in learning how to self manage care
• Initiate and support health education activities
• Identify community needs and resources
• Provide clinical leadership
• Participate in established performance evaluation process and professional development goals.
• Attend relevant conferences, workshops and other in-service events as approved.
• Perform other related duties as assigned by the Executive Director and/or Physician Lead.

Qualifications and Requirements:

• Graduate degree in Social Work from a recognized university.
• Minimum 3 years combined education and experience in the human service field. Experience related to community based mental health preferred.
• Registration with Ontario College of Social Work and proof of professional liability insurance
• Good understanding of relevant provincial and local legislation and government policies, procedures and practices pertaining to services provided by social workers
• Knowledge of therapeutic models of individual, group or family counseling and the ability to apply same. Expertise in brief treatment approaches and Cognitive Behavioural Therapy an asset.
• Knowledge of client-centered philosophy, basic principles and practices of community service delivery and short-term treatment options.
• Knowledge of community resources connected to the provision of mental health and related services.
• Demonstrated good interpersonal and networking skills.
• Ability to anticipate crises and apply crisis theory during crisis situations as appropriate.
• Demonstrated skills in assessment, program planning, implementation and evaluation, health promotion and community development.
• Proven flexibility and ability to adapt positively to change.
• Computer skills.