Social Worker, Overdose Outreach Team (OOT)

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 Social Worker is responsible for providing clinical and consultative case management and social work services to priority clients and their natural supports within the Fraser Health (FH) Overdose Outreach Team (OOT).

The Social Worker provides comprehensive services and therapeutic clinical counseling to clients and their natural supports, which includes conducting comprehensive social work and psychosocial assessments of clients and their natural supports using a variety of assessment tools to provide treatment services.

Provides clinical support to the interdisciplinary team including physicians in the development of care plans and services provided within the assigned area of responsibility.

Participates on local committees and planning bodies to identify areas of improvement in the efficiency and effectiveness of service delivery to enhance client care services and reduce service gaps.

Primarily the work is done on an outreach basis to meet the needs of the clients and to provide integration and continuity across the care continuum.

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

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

Responsibilities Conducts comprehensive social work and psychosocial assessments, counselling, referral and advocacy for clients and their natural supports connected to OOT and OOT related programs / services.

Provides comprehensive therapeutic and crisis intervention services by exploring psychosocial response to identify problems, personal concerns and treatment objectives, and to facilitate change in coping style, behavior, attitude and feelings.

Works with the client, their natural supports, community supports and interdisciplinary team to coordinate services, manage cases and facilitate meetings.

Ensures follow up to best support client engagement along the continuum of care. Provides intensive 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.

Provides harm reduction education, counseling, supplies and support including episodic overdose prevention services (eOPS witnessed consumption) and drug checking in partnership with other team members.

Builds trusting relationships with people who use substances and their supply networks to optimize access to community health interventions (e.

g. drug checking) and communication (i.e. drug alerts). Establishes and maintains effective relationships with community social service agencies by facilitating communication and decision-making around client care, and by identifying gaps in services and working with the Overdose Response and Vulnerable Populations (ODRVP) team to improve services for clients at risk for overdose.

Participates in clinical consultation and education within OOT regarding psychosocial factors affecting client care and 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 clients at risk for overdose.

Collaborates with clinical and community agencies to address barriers to clients that exacerbate risk. Receives referrals from care management personnel and other members of the interdisciplinary team to assist clients and / or their natural supports 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 ODRVP team and other care providers.

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

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

Participates in program evaluation and / or quality improvement by identifying opportunities for change and formulating recommendations to support OOT related initiatives.

Performs other related duties as assigned. Qualifications Education, Training & Experience Bachelor’s degree in Social Work from an approved school of Social Work.

Current full registration with the BC College of Social Workers. Two years recent, related experience in a complex healthcare environment such as a community harm reduction setting including one year experience working with clients who have been systematically marginalized with multiple health 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.

Current First Aid and CPR Level C. Skills & Abilities Demonstrated ability to work with priority and culturally diverse populations related to substance use and the toxic drug-poisoning crisis, including Indigenous and LGBTQ+ communities.

Demonstrated ability to do outreach to non-traditional environments where people gather (i.e. festivals, witness consumption spaces).

Demonstrated orientation to practice that deeply listens to and honours the knowledge of the people we serve, which includes radical allyship with people who use drugs, harm reduction, cultural humility and safety, sex-positive, trauma and resiliency-informed practice.

Knowledge of legislation and government policies and procedures that relate to substance use practices and how they may affect client care, resource access or practice guidelines.

Crisis prevention / intervention, problem-solving skills and conflict resolution / de-escalation skills. Ability to work independently and collaboratively in a team environment as well as capacity to work in partnership with other community agencies with minimal supervision.

Demonstrated ability to communicate effectively both verbally and in writing with clients, families, team members and community agency personnel.

Ability to operate related equipment including applicable software applications. Physical ability to perform the duties of the position.