Employment Type: Permanent

FTE: 1.0 FTE (40 hours per week)

Work Schedule: Weekdays - Dayshift

Summary of Position

Calgary Foothills Primary Care Network (PCN) is a group of family physicians and health care professionals in northwest Calgary and Cochrane collaborating with various external stakeholders to deliver the best possible primary care. The PCN has established a team environment where individuals are encouraged to take initiative, be creative and contribute to ongoing decision-making

The PCN’s Extended Health Team (EHT) is comprised of registered nurses, clinical pharmacists, kinesiologist, occupational therapists, physical therapists, social workers family physicians, nurse practitioners and mental health consultants. The team helps patients with complex chronic health conditions who struggle with psychosocial factors to self-manage chronic conditions, set achievable goals and access additional resources and support. Group and individual appointments or home visits are tailored to the patient’s needs.

Coordinated Attachment is a specialized, transitional medical home for complex patients who have issues with the psychosocial realm or chronic disease management. Patients are supported by a Primary Care Provider and allied health team of Social Worker, Behavioural Health Consultant and nursing team (Registered Nurse & Licensed Practical Nurse).

Reporting to the Program Manager, the Social Worker supports EHT and Coordinated Attachment by collaborating with the family physician, CFPCN multidisciplinary teams and community/external partners to provide patient-centered care for those with chronic disease and/or complex health conditions.

Key Responsibilities

Key aspects of the position may include, but are not limited to:

• Connecting patients and their families to identified resources that address their immediate needs and then assists them to be self-reliant in the future
• Liaising and advocating with appropriate government and community agencies in conjunction with the patient, including completing referrals
• Conducting cognitive assessments using a team-based approach, which may include cognitive screening of patient and/or collateral history gathering
• Working with patients on self-management by providing coaching and education to help advance their skills, knowledge and self-efficacy in adopting healthy lifestyle behaviours that are meaningful to them
• Helping to build care plans with patients who have, or are at risk of, chronic health conditions through biopsychosocial health assessment, collaborative goal setting, applicable interventions based on patient readiness, regular follow-up and evaluation of progress and case management throughout the patient’s participation in the program
• Supporting navigation of the health care system to connect patients and the medical home to applicable PCN, community and health system resources as needed
• Promoting continuity of patient care through effective written and verbal communication with the Patient’s Medical Home and those involved in the circle of care
• Building relationships and developing the Social Worker role within and outside of the PCN team
• Providing care through individual and facilitated group appointments, which may include home visits
• Consulting with hospital, community and other PCN health care providers to ensure seamless care transitions
• Participating in development, delivery, evaluation and quality improvement of health programs and evidence-based practice
• Collecting and maintaining data for service indicators, progress reports and evaluations
• Adheres to and performs activities and care within the full scope of practice as defined under the Health Professions Act

Knowledge, Skills & Abilities

• Strong awareness of community resources and referral processes
• Expertise in active listening and motivational interviewing
• Experience as a case manager
• Excellent communication (written and verbal), organization and critical thinking skills
• Strong skills in collaborating with team members and physicians
• Maintains an individual’s dignity and self-worth during all interactions
• Experience with trauma informed care an asset
• Excellent group facilitation skills
• Ability to provide evidence-based care
• Ability to work well in a team setting and independently
• Excellent computer skills are required
• Strong awareness of health assessment and documentation skills
• Ability to prioritize, manage time effectively and be flexible in a very dynamic work environment
• Ability to work flexible hours, including evenings/weekends, when required
• Accepts, implements and evaluates change with a positive attitude
• MoCA certification required

Qualifications

• Bachelor’s Degree in Social Work
• Registered with Alberta College of Social Workers
• Must possess a valid driver’s license and have access to a reliable vehicle

Employment Requirements:

• Completion of a satisfactory criminal record check and/or Vulnerable Sector Search.

Diversity & Inclusion

• Our PCN strongly believes in sustaining an inclusive, respectful and equitable working environment that represents the communities we serve. We are committed to a merit-based selection process that ensures all candidates are considered. We invite people of all ethnic backgrounds, ancestry, religious beliefs, sex, gender identities and expressions, sexual orientation, ages, marital status, family status, genetic characteristics and disabilities to apply for positions within our PCN.

Commitment to Truth and Reconciliation

• As part of our ongoing commitment to advancing reconciliation and supporting Indigenous communities, we actively uphold Call to Action 23 of the Truth and Reconciliation Commission of Canada. We are dedicated to increasing the recruitment and retention of Indigenous professionals across all levels of our organization, particularly in health and wellness roles and encourage individuals of Indigenous ancestry to apply.

If your background matches the qualifications listed above and are looking for an opportunity with a dynamic organization that is making a difference in the community, please submit your resume and cover letter.

Please note that only candidates considered for an interview will be contacted.

In the spirit of reconciliation, we acknowledge that we live, work and play on the traditional territories of the Blackfoot Confederacy (Siksika, Kainai, Piikani), the Tsuut’ina, the Îyâxe Nakoda Nations, as well as districts 4, 5 and 6 of the Otipemisiwak Métis Government and all people who make their homes in the Treaty 7 region of Southern Alberta.