Social Worker 2, Continuum of Care

Work Area: 
St. Paul's Hospital
Base Site: 
St Paul's Hospital
Temporary Full Time
End Date: 
Aug 12, 2020
Job Category: 
Licensed Practical Nurse
Acute Care Hospital


Within the context of a patient, client and family centred model of care and, in accordance with the Mission, Vision, Values and strategic directions of Providence Health Care, promotes a safe, respectful, and civil working environment for patients, residents, families, visitors and staff.

Reporting to the Social Work Professional Practice Leader and under the supervision of the designated Site Leader, and working collaboratively with the other Site and Professional Practice Leaders, the position is an integrated member of the Vancouver Community Housing Team and liaises and works closely with VCHA’s Manager of Mental Health & Addiction Housing and Community Transition Team to plan, implement and evaluate the intake, length of stay, transition/discharge goals and outcomes, and community resource needs of patients/ residents throughout the hospital and identifies related service gaps or barriers. The Social Work, Continuum of Care primarily supports patients/residents who are homeless and works closely with community housing services that provide emergency (Shelters), transitional and permanent housing to support transitions from acute care to the community. Recommends changes to the respective supervisor to facilitate durable transitions and discharges. Develops and reviews relevant policies, procedures, practice standards and reference materials related to the transition of patients/residents from intake to discharge to help ensure effective, appropriate, and timely patient/resident transition from hospital admissions to community services. Collaborates with program social workers and interdisciplinary teams regarding quality improvement initiatives, and identifies and evaluates internal and external gaps in service. Implements and communicates authorized policies, procedures, practices, standards, and related amendments and provides inservice presentations to other staff and social workers in units across the hospital. Supports staff in the application of practice, policy, procedures and standards and advises the appropriate supervisor of any gaps in service.

Participates as a member of local, provincial/federal committees to build effective relationships to more effectively link the hospital programs to community support programs and services. Participates in the development of community housing resources by troubleshooting issues and providing quality improvement suggestions. Provides consultation services to hospital social workers and interdisciplinary teams to facilitate transition/discharges that address the care needs of patients through the effective utilization of organizational and community resources. Provides direct and consultative social work services to patients, families and staff in the designated program area, focusing on how the patient’s relationships are affected by the global environment. Provides therapeutic clinical interventions within the context of a person and family centred recovery model within the mission, visions, values and strategic directions of Providence Health Care.


Ability to develop, implement and evaluate policies, procedures and standards.

Knowledge of primary care and community and housing resources.

Knowledge of the Mental Health Act as it applies to the rights and obligations of others.

Knowledge of Adult Guardianship legislation, and other government policies and procedures that relate to the care of patients and families.

Ability to identify emotional, social or environmental barriers to discharge planning.

Ability to effectively manage conflict situations and aggressive behaviour and use non-violent crisis intervention and behavioural management techniques.

Ability to work both independently and collaboratively as a member of an interdisciplinary team.

Ability to communicate effectively, verbally and in writing, with patients/residents, families, staff, community agency staff and academic institutions.

Broad knowledge of mental illness and addictions treatment including principles of harm reduction and recovery models.

Broad knowledge of other health care disciplines and their roles in healthcare.

Broad knowledge of research methodologies and methods.

Broad knowledge of counselling skills and clinical practice models, including case management models.

Broad knowledge of individual, family, group and change therapy.

Demonstrated ability to apply systems theory to practice in social work assessments and interventions.

Demonstrated ability to gather relevant data and complete a comprehensive psychosocial assessment that includes impact of Social Determinants of Health.

Demonstrated ability to understand and influence group and inter-group processes, decision making and problem solving.

Demonstrated ability to establish rapport with clients and families.

Basic understanding of trauma-informed and culturally safe care and practice.

Basic literacy to operate a computerized client care information system and word processing, email, spread sheets, and internet.

Physical ability to perform duties of the position.


Masters Degree in Social Work from an accredited university. Three (3) years of recent related experience, including one (1) year in the non-profit housing sector and two (2) years working in an acute care setting or an equivalent combination of education, training and experience.

Current full registration with the British Columbia College of Social Workers.


Plans, implements and evaluates the intake, length of stay, discharge, community liaison needs, and transition of PHC patients/residents across the continuum of community care by identifying service gaps or barriers and recommending changes to improve service delivery pertaining to patient transitions and extended patient stays. Prepares and maintains related policy and procedures for the area of service.

Identifies opportunities for quality improvement initiatives; leads and/or participates in their development, implementation and evaluation. 

Identifies research opportunities pertaining to patient/resident transition issues. Develops research protocols and conducts approved social work and/or interdisciplinary research and special projects in collaboration with other team members through methods such as identifying current trends/ gaps in literature, writing research proposals/ grant applications, following through with research methodology and disseminating research findings within an institutional and professional ethical framework. Ensures clinical practices and protocols are consistent with current research findings.

Works with the respective Social Work Site Leader to apply quality improvement and research findings to practice by drafting, implementing and evaluating policies, procedures, standards, education, and reference materials for authorization by the Professional Practice Leader and/or the Patient Resident Care Manager.

Supports the interdisciplinary program/ team to achieve program, patient and resident goals by providing clinical consultation services, advice, and guidance to other social work and interdisciplinary staff across the hospital and outside agencies on the care and management of patients in the designated program.

Acts as a clinical resource and consultant to social work and other interdisciplinary staff as needed, by supporting staff to apply policies/ procedures and standards consistently, and by problem-solving complex patient/ resident/ family care issues such as those involving the child protection act, adult guardianship, and legal/ liability exposure. Develops assessment forms and patient/resident materials, program descriptions, audit tools and clinical guidelines accordingly.

Attends and/or chairs regular meetings with social workers and other health care and social service workers to identify and problem-solve patient transition and quality improvement issues.

Attends and/or leads meetings, in-services, and corporate initiatives by methods such as presenting relevant materials/ topics to contribute to hospital, community and primary care initiatives.

Develops, builds, and enhances community relationships and communications through methods such as contacting relevant housing programs/ services, identifying program needs for communities, assisting in the development/ revision of programs, ensuring community programs are effective, and advocating on behalf of the patient/ program for the development of collaborative participation and access to inclusionary community resources.

Provides therapeutic clinical interventions to clients, families and groups in designated program area by methods such as exploring the emotional responses to identify problems, personal concerns and treatment objectives; facilitating change in coping style, behaviour, attitude and feelings; participating with patients, families, community supports and interdisciplinary team members to coordinate services, facilitate meetings and make referrals to appropriate resources.

Conducts comprehensive psychosocial assessments: interviews patient and family, obtains data regarding the patient and family, environment, living situation, financial needs, coping abilities to develop an appropriate ongoing care plan.

Collaborates with designated care management providers and interdisciplinary teams to facilitate transitions through the continuum of services for complex discharge needs. Assists patients/families with complex emotional and social needs.

Participates as a member of the interdisciplinary team in clinical consultation by methods such as interviewing the patient and/or family, assessing and determining care needs, eligibility and type of services required and arranging hospital/community meetings on admission to assist in developing and coordinating transition/discharge plans for patients with complex needs. Authorizes community services for clients requiring emergency housing including facility/ shelter placement, home support and adult daycare and collaborates with hospital and community services to determine discharge needs, alternative level of care for clients and the effective utilization of client resources.

Attends clinical/care conferences as a member of an interdisciplinary team providing education and consultative services to provide input from a social work perspective on a variety of care issues in relation to the patient and program effectiveness to ensure proper and effective treatment of the client.

Acts as a resource to provide consultative and direct services to clients, families and staff and community professionals regarding issues such as Adult Abuse, Neglect and Self Neglect (Adult Guardianship), capability, advanced care planning, interpersonal violence, immigration, housing/ shelter, Public Guardianship issues, and public authorities (courts, police).

Assists with extended leave certification as required under the Mental Health Act by methods such as reviewing conditions of leave and determining if client is following conditions. Liaises with community partners to update Extended Leave Certification to provide continuity of care.

Participates as a member of local committees by methods such as engaging in program/ practice evaluation, identifying opportunities for change, assessing available resources, analyzing outcomes and identifying areas for improved efficiency and effectiveness in service delivery to enhance patient service within hospital programs and reduce gaps in service in the community.

Participates in group meetings by performing duties such as facilitating group sessions by providing clinical counseling services and providing therapeutic and/or psycho-social education as required.

Maintains broad knowledge of developments related to the Social Work profession by methods such as reviewing literature in designated program area, consulting with, and seeking supervision from, clinical and community experts within the field, evaluating clinical practice and participating in professional development activities to improve care through new practice models.

Maintains assessment, treatment and other related materials for the site/ program and a variety of records such as workload statistics, care data, and information on continuous quality improvement projects. Records information into approved formats, collating data, analyzing trends, and accounting for variances.

Provides teaching and supervision to social work interns as assigned by methods such as providing guidance and the opportunity to observe and take an active role in the treatment of social work clients and families.

Performs other related duties as assigned.