Carefirst Family Health Team is a non-profit, primary healthcare clinic that includes a team of family physicians, nurse practitioners, registered nurses, social workers, dieticians, and other professionals who work together to provide community-centred primary health care services and programs to a diverse community in the Greater Toronto Area.

With two clinics located in Scarborough and Richmond Hill, the Family Health Team is committed to meeting the Ontario government’s strategy to improve access to comprehensive primary health care for Ontarians. Our team collaboratively strives to improve the health of patients and families by providing culturally sensitive and holistic primary and specialized health care services.

We are currently seeking a Social Worker to join our Family Health Team.

The Social Worker will work with patients in need of specialized targeted care, otherwise known as “complex patients”. Complex patients may have four or more physical and/or mental health conditions, an overlay of social determinants of health, and an overlay of acute hospital use.

The position will conduct a patient-centred assessment using chart review, assessment and interview, and create a care plan linking the patient with their primary care practitioner, IHP clinicians, specialists, and community resources in order to more fully address patient healthcare needs and provide coordinated care.

The Social Worker will also provide clinical social work services (counselling/therapy) to patients and families of the FHT with a focus on, but not limited to, ethnic and new immigrant communities. The social worker works to restore, maintain and enhance emotional and social functioning by assisting patients to mobilize strengths, recognize coping capacities, and modify ineffective patterns of behaviour. The social worker links patients/clients and families to resources and provides psychosocial education related to health promotion and well-being.

The Social Worker will be expected to function within her/his full scope of practice entailed in Ontario College of Social Workers and Social Service Workers, Code of Ethics and Standards of Practice, 2000.

This position will collaborate with members of an interdisciplinary team to implement patient and family-centred care in consultation with individuals and their families

Terms: Full Time Permanent

Location: 300 Silver Star Blvd, Scarborough and 420 Highway 7 E, Richmond Hill

Responsibilities:

• Coordinate and manage Carefirst’s various programs and services as they pertain to social work
• Provide leadership and consultation to a team of social workers including supervisory work related to staff and daily operations
• Assist with the development and implementation of social work policies and procedures
• Interact with community agencies involved in health and social services, represent Carefirst at meetings and events in the community
• Act as convenor for case conferences and be responsible for chart auditing on a routine basis
• Monitor and evaluate the overall performance of the social work team
• Assess and triage social work referrals
• Monitor targets and compile quarterly statistic reports
• Conduct eligibility and service needs assessments
• Develop, initiate and coordinate individualized care plans for eligible patients/clients and provide ongoing resource management, case management and discharge planning as appropriate
• Provide client-centered care through administration of comprehensive patient needs
• Perform psychosocial assessments, diagnosis and therapeutic intervention/counselling to patients to assist them to achieve optimum social functioning and psychological wellbeing
• Offer counselling services, with particular regard to individual and family issues and decisions that impact the health of patient and family
• Advocate for patients and their families in matters affecting health
• Identify and support access to community, volunteer and professional services and programs appropriate to patient/client needs
• Perform other duties as available: practicum supervision, collaboration opportunities etc.

Requirements:

• Master of Social Work from an accredited School of Social Work

• Current registration and in good standing with the Ontario College of Social Workers and Social Service Workers

• Current registration with the Ontario Association of Social Workers

• At least 3 years clinical case management experience, in a primary health care/community-based setting

• Demonstrated case management and coordination experience

• Familiar with in-home health care and assisted living services

• Experience in developing, implementing, monitoring, and evaluating health promotion programs and activities Outstanding assessment skills and ability to exercise good judgment and instincts in order to understand patient/client needs

• Proficiency in current assessment, psychotherapy and psychosocial counselling techniques, including proficiency in the use of Cognitive Behavioural Therapy, strong holistic assessment skills, and Mindfulness Techniques

• Ability to interpret social, emotional and behavioral problems as related to medical conditions, and to develop appropriate treatment plan

• Sensitivity and awareness of cultural, racial, economic, and socially diverse communities of various ages

• Strong ethnical standards and discretion handling sensitive information

• Experience in couples counselling and Geriatrics/working with seniors an asset

• Experience treating sexual abuse/assault as well as complex trauma an asset

• Experience in teaching social work students and other interdisciplinary learners

• Experience with Electronic Medical Record (EMR) systems, InterRAI CHA Assessment and CIMS an asset

• Valid CPR/first aid certification

• Ability to speak a second language such as Cantonese and/or Mandarin is an asset

• A valid vulnerable sector police record check completed within one year

Benefits:

• Dental Care
• Extended Health Care
• HOOPP
• Comprehensive Orientation Program
• Training and Education Subsidy

Application Deadline: November 9, 2025

Carefirst is an equal opportunity employer. We are also committed to an environment that is barrier free. If you require accommodation during the hiring process, please inform us in advance to arrange a reasonable and appropriate accommodation.

While we thank all candidates for their interest, only those selected for an interview will be contacted.