Social Worker (Msw), Assertive Community Treatment (Act)

1. Establishes a therapeutic relationship with the client through the use of interpersonal and interviewing techniques, in person and/or over the telephone, to ensure the client's choice and autonomy in decision-making and care planning including the client's right to dignity and privacy.
2. Screens referrals, provides individualized client assessments, interprofessional care planning and interventions including clinical care, when appropriate and referral services for clients with multiple complex chronic conditions; assists clients to achieve an optimal level of function by facilitating timely and appropriate health services and utilizing a variety of resources and services; collaborates with the primary care provider, client, the family/supports/caregivers, other health care professionals, clinics, hospitals and other community resources to identify and resolve client care issues and coordinate the integration of care and services.
3. Develops a comprehensive shared patient/client care plan, in collaboration with the interprofessional team, primary care provider, client and/or family, other healthcare providers and/or referring clinics; facilitates and supports the transition of the client care plan to the referring source, primary/community care provider and/or community agencies.
4. Provides direct client care and identifies other care services required in accordance with applicable guidelines, policies and evidence-based best practice; provides comprehensive explanations of care to the client and family, as appropriate.
5. As required based on the local community model, makes decisions on client specific direct care tasks; assigns direct client care tasks to Community Health Workers and when appropriate delegates client specific direct care tasks to Community Health Workers; provides in-home demonstrations and training to standards of practice for assigned and delegated client specific tasks; ensures that the Community Health Worker has the necessary knowledge, skills and support to perform the delegated tasks within the clearly defined limits; collaborates with the Community Health Nurse - Licensed Practical Nurse in the monitoring of Community Health Workers performing clients specific delegated direct care tasks.
6. Facilitates care conferencing to review client care plans, in collaboration with the interprofessional team and primary care provider to determine timing and referral to other services and/or interventions to improve client outcomes; initiates, monitors and evaluates the appropriateness and effectiveness of the short and long term care plan to meet specific client goals; develops next steps in collaboration with the client and family; develops and supports a transition process for achieving client care goals across the care continuum including discharge and/or transfer to other services, as required.
7. Discusses clinical findings with client/family, in collaboration with the interprofessional team to develops action plans and sets goals directed at clinical needs, self -management, self-care and improved health-related quality of life; accesses system information and resources to review client data such as medical history, progress notes, consultation reports, lab reports and incorporates findings into the care plan; plans, organizes and establishes priorities by using resources effectively and efficiently; responds to unanticipated events and/or changing client or service assignment needs, as needed.
8. Supports clients and their families before, during and after interprofessional conferences and clinic visits by providing information through their decision-making process regarding treatment options; advocates on behalf of the client/family to support their choices and needs and provides direct care to client within the clinic/community/home as they transition to another program, service or healthcare provider.
9. Arranges and participates in joint home visits to clients and/or families with other healthcare professionals, as required; provides advice to the client and/or caregiver about available community resources.
10. Provides health counseling to clients including education, self-management, self-monitoring and wellness/health promotion/prevention through a combination of clinic, telephone or home visits; collaborates with other healthcare professionals in clinics, community programs and services to facilitate the flow of information through a variety of settings within the primary & community care network.
11. Maintains clinical records such as intake screens, client assessments, clinical interventions, treatment formulations, care plans and progress notes; maintains statistical information on clients in accordance with established policies, standards, and procedures.
12. Maintains professional practice growth, knowledge and expertise to reflect current standards of practice by reviewing relevant literature, attending educational workshops and in-services, consulting and networking with other health care professionals.
13. Participates in department quality improvement and risk management activities by identifying client care issues and collecting data; participates in research opportunities, as required.
14. Participates in the orientation and ongoing education of nursing staff and students by providing information and acting as a preceptor as appropriate.
15. Provides input in the development and revision of standards of care, policies and procedures and advocates for improvements in clinical practice, health care and health care services; participates in the development, implementation and evaluation of quality improvement initiatives within the program by providing recommendations to the Manager.
16. Performs other related duties, as assigned.

Current practicing registration as a Registered Nurse with the British Columbia College of Nurses and Midwives (BCCNM).

One (1) year recent related clinical experience assessing and treating complex geriatric and/or adult patients with chronic health conditions in an acute or community/outpatient care setting including recent experience in care and discharge planning, or an equivalent combination of education, training and experience.

Valid BC Driver's license and access to a personal vehicle for business-related purposes.

• Demonstrated knowledge, skills and competence in the areas such as gerontology and adults living with complex frailty and chronic illnesses
• Demonstrated ability to complete initial and ongoing client assessments and provide nursing care through therapeutic interventions
• Demonstrated ability to communicate effectively, both verbally and in writing
• Demonstrated ability to integrate and evaluate pertinent data from multiple sources to problem-solve effectively
• Knowledge of broad health care services, community resources agencies and their role in providing a continuum of care
• Ability to promote client-focused care including sensitivity to diverse cultures and preferences
• Ability to independently manage and prioritize clients with diverse healthcare issues
• Ability to teach clients and others about topics essential to health care, health promotion and care self-management using care management principles
• Ability to work effectively in a dynamic environment with changing priorities
• Ability to work independently and as a member of an interprofessional team
• Ability to operate related equipment including applicable software applications
• Physical ability to perform the duties of the position

Fraser Health is the heart of health care for over two million people in Metro Vancouver and the Fraser Valley in British Columbia, Canada, on the traditional, ancestral and unceded lands of the Coast Salish and Nlaka’pamux Nations and is home to 32 First Nations within the Fraser Salish region.

People - those we care for and those who care for them - are at the heart of everything we do. Our hospital and community-based services are delivered by a team of 48,000+ staff, medical staff and volunteers.

We are committed to planetary health and value diversity in the work force. We strive to maintain an environment of respect, caring and trust. Fraser Health’s hiring practices aspire to ensure all individuals are treated in an inclusive, equitable and culturally safe manner.

Together, we are the heart of health care.

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