IDENTIFICATION Department Northwest Territories Health and Social Services Authority Position Title Medical Social Worker- Home Care Position Number(s) Community Division/Region(s) 57-95065 Yellowknife Community Health/Home Care/Yellowknife PURPOSE OF THE POSITION To provide psychosocial assessment, facilitation, advocacy, case coordination and management, and counseling services to high-risk clients and their families, who encounter psychosocial concerns as a result of illness, injury or disability. The incumbent coordinates community resources and referrals to facilitate health transitioning; long term planning; exchange of information and to expedite the discharge planning process. SCOPE The Northwest Territories Health and Social Services Authority (NTHSSA) administers all Public Health, Home Care and general physician services throughout Yellowknife, Dettah and N Dilo as well as all regional health and social services delivered in Fort Resolution and Lutsel K e. The NTHSSA provides and supports the delivery of community based health care services to adults and children in order to enhance the health and well-being of communities through excellence, accountability and respect for regional diversity. Located in Yellowknife and reporting to the Manager - Home Care, the incumbent provides community based psychosocials, supportive services on behalf of the Home Care Program in Yellowknife, N Dilo and Dettah for clients ranging from pediatric to geriatric. The Home Care unit consists of a multi-disciplinary group that includes RN's, Home Support Workers, an Occupational Therapist, LPN, Community Mental Health RN, Medical Social Worker, Physiotherapist, and Registered Dietician who provide care to the clients in order to restore or maintain the health of clients after acute/chronic illness, injury or disability. August 1, 2016 GNWT Job Description Page 1 of 6
Psychosocial issues directly impact the health care system by increasing costs and diminishing resources. Coordination of available resources and community access is a valuable service for promoting health and wellness. The Medical Social Worker (MSW) is a sole provider and works independently assisting highrisk clients and their families in a variety of settings i.e. in their homes, at school or in the hospital. He/She must be self-directed and highly motivated; must take initiative to quickly identify issues, plan a course of action, coordinate all resources in a timely manner; communicate and collaborate with all stakeholders; and review, revise and evaluate the process. The incumbent effectively manages their caseload and participates on several multidisciplinary teams. RESPONSIBILITIES 1. Client Assessment: Assesses high-risk clients for psychosocial problems related to their illness, injury or disability. Assesses the clients' psychosocial status and identifies specific needs in view of their care requirements. Promotes effective communication to facilitate information sharing between client, staff, physicians, and other health care providers and outside agencies. Consults/collaborates with interdisciplinary members, health, social, and community agencies regarding client care needs. Provides ongoing follow up and evaluation to determine efficacy of client interventions; Documents client's needs assessment and develops a service plan with projected goals and intervention planning. 2. Planning Care: Coordinates client needs and available resources for high-risk clients and their families to facilitate re-integration into the community. Sets priorities and establishes goals of care that are responsive to the health needs and preferences of the client and family, the home setting and cultural context. Facilitates health transitioning for clients from hospital to home/community. This includes direct social work and counseling related to changes in lifestyle, relationships, physical functioning, employment and financial concerns and emotional-psychological functioning. Collaborates/consults with clients and their families, interdisciplinary team members, community resources and other centers in order to reduce duplication and identify potential gaps in services. Advocates on behalf of clients and families to obtain services and resources to address unmet care needs and fair processes. Coordinates and prioritizes caseload and reviews monthly with Manager, Home Care. Provides resource management, information and referrals. Prepares Health Suite Health Information System records and statistical information in a timely manner. August 1, 2016 GNWT Job Description Page 2 of 6
Initiates and participates in case conferences to share pertinent information concerning client concerns or progress, and to utilize team skills and resources to provide the most efficient and effective service delivery. Participates and collaborates in discharge planning with Stanton Territorial Hospital. Reviews, evaluates and adjusts the care plan as goals are met, on a continuous basis and annually on long-term clients. Educates the client and family to develop an understanding of how service providers, client and family work together to reach desired goals. 3. Provision of Care: Implements plan of care following established policies, procedures and practices of the organization and the Canadian Social Workers Association in order to ensure safe and professional care. Makes frequent decisions about the most appropriate, effective and efficient mode of communication among interdisciplinary team members. Ensures that professional services outlined in care plan are implemented and evaluated on a case-by-case basis." Provides appropriate, independent interventions in unanticipated, unstable situations Encourages and supports clients and their families to be responsible for promoting, maintaining and enhancing their health and independence. Fosters a positive working relationship with clients and their families, other service providers and community agencies. Advocates on behalf of clients to obtain services, resources and fair processes, or lobbying for the development of services and programs to address gaps in services. Documents a written plan of care and ongoing progress to aid in interdisciplinary communication and to meet legal requirements. Partners with appropriate community agencies and service providers to develop strategies to address broader community needs. 4. Professional and Program Development: Contributes to her/his own professional development and the development of the Home Care program in order that the highest standards are reached and the program continues to offer services that are both cost efficient and effective. Works for the implementation and maintenance of workplace conditions and policies, which are current with the standard of practice of the Social Worker Code of Ethics. Reviews strategic planning both for client care and Medical Social Worker position, i.e. goal setting, program enhancement with all stakeholders Identifies personal educational and training goals annually with Manager, Community Health. Furthers own education and personal development. Acts as a resource for students accepted at Home Care. Orients new staff. Identifies and participates in opportunities to promote public relations, i.e. presentations, interviews, training, education Participates in assessment of program development needs; establishing policies and reviewing present practices for the Medical Social Worker position. August 1, 2016 GNWT Job Description Page 3 of 6
WORKING CONDITIONS (Working Conditions identify the unusual and unavoidable, externally imposed conditions under which the work must be performed and which create hardship for the incumbent.) Physical Demands As typically associated with office positions. Environmental Conditions The incumbent will spend 30% of their day in client's home where the incumbent may be (and often is) exposed to unsanitary conditions, cigarette smoke and loud noises which may make the incumbent sick (i.e. allergies) and pose a safety risk. In addition, the incumbent will be exposed to all weather conditions (ranging from -40 to +30) when driving to and from client's homes. The constant changes in temperature (office - vehicle - home - vehicle - etc.) may make the incumbent sick. For 30% of their shift an incumbent may be exposed to communicable diseases, blood and body fluid that can result in potential health risk to the incumbent. The other half of the day will be spent on administrative duties within an office setting. Sensory Demands This position requires a high degree of concentration and attention to detail but can also expect numerous and continues interruptions during the working day. The incumbent can be called upon at any given time to attend various situations and/or locations Working within the client home may be extremely distracting and make normal assessment and diagnosis more difficult as these settings may be distracting for both the incumbent and the patient (noise level, family interruptions, visual commotion, etc.). Focused attention to verbal and non-verbal communication of potentially volatile, difficult, intoxicated and verbally and/or physically abusive clients. The remainder of the day will be spent on administrative duties within an office setting where the incumbent may be required to focus on a computer terminal. Mental Demands The MSW has the opportunity to develop relationships with the clients of the Home Care Program. The person is expected to remain calm, controlled and professional, regardless of the situation and demonstrate compassionate care to the client, family and other members of the health care team. The MSW is required to support a peaceful and dignified death of those residents that may cause significant emotional stress. August 1, 2016 GNWT Job Description Page 4 of 6
There is uncertainty in knowing what to expect while at work, especially in uncontrolled settings (i.e. home visits). There is legitimate concern about risk of verbal or physical assault and unknown and unpredictable situations (i.e. patients or family members under the influence of alcohol, demanding and confrontational family members). Within the health care setting there can be significant lack of control over the work pace, with frequent interruptions that may lead to mental fatigue or stress. The incumbent must make decisions quickly that could have far reaching effects on the client's well-being. Conflicting priorities and very short deadlines place mental demands on the incumbent. The incumbent operates independently and is responsible and accountable for the decisions made while performing the duties of the position. Judgments must be made with very little support or supervision. Parameters and policies are not entirely in place in regards to the provision of homecare services. KNOWLEDGE, SKILLS AND ABILITIES The Medical Social Worker must have a health background in order to identify and address health issues as they impact on the client and their families. He/she must have strong interpersonal and communication skills in order to interact with clients, their families, community resources, outside agencies, and other health care professionals. The Medical Social Worker must have knowledge of and an ability to apply psychosocial processes (such as assessment, planning, coordination, facilitation and evaluation). Ability to teach and communicate effectively with clients and colleagues of different ages and cultures, using appropriate English language skills, in order to understand and respond to client needs and work together in the client's best interests. Strong communication skills both verbal and written. Working knowledge of the biological, physical and behavioral sciences in order to recognize interpret and prioritize issues and determine and implement a plan of action based on accepted standards of practice. Flexibility is critical to the effective and efficient use of resources and to maintaining professional peer relationships. Ability to function within the interdisciplinary team setting and promote teamwork practices i.e. attendance at morning huddles with other disciplines, staff meetings, and team/case conferences. Ability to be self-directed, meets deadlines, prioritize own workload, and manage various projects and requests simultaneously. Demonstrate sound judgment and creative problem solving skills, sets priorities, makes decisions independently, has good listening skills and a non-judgmental attitude. Must be able to function within the community setting, problem solve and make decisions with little supervision, while interacting with acute and chronically ill clients with changing needs. Demonstrated knowledge of the community and its resources and provide care that is culturally sensitive August 1, 2016 GNWT Job Description Page 5 of 6
Has strong interpersonal skills to facilitate effective communicate with other team members, clients, their families, and outside agencies, i.e. public speaking, counseling skills. Working knowledge of territorial acts, legislation regarding social services programs An ability to operate a desktop computer in order to send and receive electronic mail, compile statistical data and conduct research over the internet. Typically, the above qualifications would be attained by: A Baccalaureate Degree in Social Work from a recognized university with five years current and directly related experience or social work experience in a health care environment. Equivalencies would include but are not limited to a Diploma in Social Work and at least seven years directly related experience; or an equivalent combination of social work education and experience. ADDITIONAL REQUIREMENTS Yellowknife Regional Requirements Current membership and in good standing with a Provincial or Canadian Association of Social Workers is required. Basic CPR must be obtained prior to hiring and with mandatory certification every 2 years. Must possess a valid Northwest Territories Class 5 driver's license in order to provide home visits to clients. Position Security (check one) No criminal records check required Position of Trust criminal records check required Highly sensitive position requires verification of identity and a criminal records check French language (check one) French required French preferred French not required August 1, 2016 GNWT Job Description Page 6 of 6