Sexual Health and Blood Borne Infections Social Worker - Abbotsford

Detailed Overview

Within the context of a client and family centred care model and in accordance with the vision and values of the organization, the Sexual Health and Blood Borne Infections (SHBBI) Social Worker is responsible for providing clinical and consultative case management and social work services to priority clients and families living with HIV and / or HCV.

As an integrated member of the Fraser Health SHBBI team, the Social Worker provides clinical consultation and education to the clinical team on HIV clients identified with complex needs.

As part of the multidisciplinary HIV clinical team the Social Worker will collaborate on client assessments and the development of care plans that focus on overall health stabilization and physical and emotional wellbeing.

The SHBBI Social Worker plays a central role as a liaison, and an education resource with community agencies and throughout Fraser Health.

Applies advanced knowledge, skill and clinical experience in facilitating communication and decision making around client and patient care.

Responsibilities Provides advanced psychosocial assessment, counselling, referral and advocacy for clients and families living with HIV.

Provides crisis intervention and problem solving to effectively support those who engage in high-risk behaviour with a variety of biopsychosocial difficulties.

Identifies and provides referrals, in accordance with established protocols, to appropriate resources / services based on clients' needs.

Ensures follow up to best support client engagement along the continuum of care. Provides intensive HIV case management services to clients noted as having acute complex care needs.

Completes collaborative assessments and responds by coordinating, monitoring and frequently evaluating individualized care plans that address the client's needs.

Establishes and maintains effective relationships with community social service agencies, facilitating communication and decision making around client care, identifying gaps in services and working with the STOP team to improve services to individuals living with HIV.

Provides clinical consultation and education to the SHBBI Nursing Outreach Team regarding psychosocial factors affecting client care engagement.

Provides up to date accurate information regarding changes in system navigation ensuring timely and efficient responses to client care needs, including relevant legislative systems applicable to client populations served.

Maintains client records by documenting client referrals and assessments, charting information, preparing progress notes and reports in accordance with established standards, policies and procedures and in in compliance with regulatory requirements.

Participates in inter-professional planning, evaluation and development of protocols to enhance system processes and resources for HIV positive individuals referred to the SHBBI Team.

Collaborates with clinical and community agencies to address identified high-risk barriers to client care for the goal of sustainment / engagement in HIV treatment and care.

Receives referrals from care management personnel and other members of the interdisciplinary team to assist clients / families with complex emotional or social presentations through the system of care.

Requests and / or attends clinical case conferences for client reviews, consults on new referrals and discusses transition / discharge plans in collaboration with the SHBBI nursing team and other care providers.

Provides consultative and / or direct services to clients, families, team members and community health professionals to navigate psychosocial systems such as immigration, financial instability, housing, legal advocacy and mental health and addiction services.

Maintains a variety of documentation and records. Collects and provides requested data to the SHBBI clinical team as required.

Participates in program evaluation / quality improvement by identifying opportunities for change and formulating recommendations to support SHBBI initiatives and services.

Performs other related duties as assigned. Qualifications Education and Experience Bachelor's degree in Social Work from an approved school of Social Work.

Two years recent, related experience in a complex healthcare environment such as a community setting including one year experience working with marginalized clients with multiple health issues including HIV, mental health and substance use issues.

Or an equivalent combination of education, training and experience. Valid B.C. driver's license and access to a personal vehicle for business-related purposes.

Skills and Abilities Comprehensive skills including trauma informed practice and intervention. Knowledge and understanding of emotional and mental health issues related to illness, injury, and client and family cultural dynamics.

Comprehensive knowledge of other health disciplines and their role in HIV care, prevention, and in a population and public health framework.

Comprehensive knowledge in working with priority populations related to SHBBI initiatives including but not limited to LGBT2SQQ+, Indigenous Populations and populations who use substances.

Ability to educate and provide consultation to clients, families and healthcare professionals. Ability to develop, coordinate and deliver in-services, presentations, psycho-education and support to groups.

Ability to provide leadership to the interdisciplinary team in care planning for the effective utilization of client resources.

Ability to make effective referrals, reflecting in-depth knowledge of community resources and strong collaborative skills in working with community health and social agency personnel.

Ability to establish and maintain strong, collaborative working relationships with both clinical staff and external community agencies for the purpose of client centered care.

Demonstrated ability to work independently with minimal supervision. Advanced knowledge of legislation and government policies and procedures that relate to the client population served.

Understanding of the local, regional and provincial initiatives that may affect client care, resource access or practice guidelines within this setting.

Demonstrated ability to conduct complex biopsychosocial assessments. Demonstrated ability to apply systems theory to practice in Social Work assessment and intervention.

Demonstrated ability to draw out and honour information that will contribute to understanding the clients' situation. Demonstrated ability to communicate effectively both verbally and in writing with clients, families, team members and community agency personnel.

Demonstrated ability to adjust to new or unexpected events utilizing components of crisis intervention and problem solving skills.

Demonstrated ability to deal effectively with conflict situations. Ability to operate related equipment including applicable software applications.

Physical ability to perform the duties of the position.