GAIN Community Social Worker - Senior Persons Living Connected

Apr 30, 2021
Scarborough (Birch Cliff / Cliffside West), Ontario

The social worker in Geriatric Assessment Intervention Network (GAIN) Community Team participates fully in the process of comprehensive geriatric assessment (CGA) and delivers community specialized geriatric services. Contributes to all aspects of the patient care including comprehensive assessment utilizing various standardized tools and clinical judgement.

Principal Responsibilities and Duties:

1.    Participate in inter-professional Comprehensive Geriatrics Assessment (CGA)

  1. Complete clinical triage for new referrals
  2. Gather and record data within all domains of Comprehensive Geriatric Assessment (CGA)
  3. Responsible for the identification of patient/family goals and coordinated care planning
  4. Conduct interview with patient and family, utilizing strength-based and person-centred approach
  5. Implement care plans, in collaboration with patient and caregiver/s, to maximize independence at the highest level possible

2.    Provide patient and family-centred case management

  1. Conduct assessments, prepare person-centred/goal-oriented care plans, and provide case management for patients, as part of the GAIN Community Team
  2. Provide crisis management, counseling and follow-up plans, as required, including liaising with the patient’s family/caregiver and/or other care providers
  3. Co-ordinate and monitor self-directed patient caseloads with the inter-professional team
  4. Identify, document occurrences, and take corrective actions, when required
  5. Plan, organize, and facilitate case conference meetings with team
  6. Work with patient and caregivers on individual, couple and family issues; and liaises with community partners including primary and community care providers
  7. Provide ongoing case management and support to families, caregivers and patients to improve and/or maintain function
  8. Maintain accurate records in care plans, progress notes, and statistical reports, as required
  9. Participate in regular meetings with the Director of Care Services and the inter-professional team to assist in program development and ongoing monitoring and evaluation

3.    System navigation, information and referrals

  1. Focus on supporting patients to manage transitions, whether between GAIN’s own services or across multiple service providers
  2. Enhance system navigation, care coordination and transition support for patients to/with the most appropriate provider/s, setting/s, and type/s of interventions
  3. Participate in the prevention of adverse outcomes through environment optimizing, and provide support to assist in minimizing the risk of traumatic and adverse events (medically and psychosocially)
  4. Refer to Seniors Persons Living Connected or external support groups to enhance the adjustment of patients/caregivers

4.   Promote health and safety of patients, staff and self

4.1. Comply with the Seniors Persons Living Connected “Client Safety,” “Risk Management,” and “Health and Safety” policies, and regulated requirements of affiliated professional association

4.2. Ensure that all policies and procedures on service quality, staff, and client safety are followed

4.3. Follow the policies, procedures and department handbook as required by the position, with the emphasis on health and safety for both patients and self

4.4  Comply with, and conform to all legislated safety regulations, and perform work safely, according to departmental and organizational procedures and policies

3.5  Deliver services in a safe and supportive manner

3.6  Work safely at all times and ensure the safety of self, co-workers and patients by preventing hazard and reporting hazards to the supervisor.

5.    Ensure quality of service provision and continuous quality improvements

5.1. Identify and report concerns or issues to the supervisor immediately

5.2. Identify and make improvements in processes and practices

5.3. Monitor, evaluate, and make recommendations on quality of standards and procedures

Other reasonable duties that may be assigned from time to time


This job description indicates the general nature and level of work expected. It is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities required by the incumbent. Incumbent may be asked to perform other duties as required.


  • Master’s Degree in Social Work required
  • Membership in good standing with a regulatory body in Ontario - Ontario College of Social Workers and Social Service Workers (OCSWSSW) required
  • Certificate/s in counselling an asset
  • Valid First Aid and CPR certificate an asset

Skills & Experience:  

  • Two to three (2-3) years experience working with an inter-professional team in a healthcare setting
  • Experience working with older adult population and knowledge of geriatric conditions
  • Extensive knowledge on how to effectively serve an increasingly aging population with complex medical, functional, cognitive, and psychosocial needs
  • Knowledge of assessment, counseling, and case management
  • Sound understanding of community resources (social, legal, health and financial)
  • Good assessment skills for evaluating dementias, cognitive impairments, depressions, and deliriums, mental health and addictions
  • Sensitive to the cultural needs of patients from various ethnic groups
  • Excellent interpersonal, communication, decision-making and assessment skills
  • Ability to work independently and co-operatively in a busy multi-disciplinary situation
  • Experience in conducting home visits for patient care an asset
  • Fluency in a second language an asset

Working Conditions:

  • Required to conduct home visits with patients and caregivers; working alone in the home
  • Work occasional evenings and weekends, as required
  • Regular interruptions to support patients’ needs and crises
  • Regular exposure to computer terminal
  • May be exposed to communicable diseases

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This job is from CharityVillage
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