Social Worker, Community Health

Are you a registered Social Worker looking for an opportunity to make a meaningful impact in your community? Do you thrive in a collaborative environment where you can advocate for clients and connect them with essential services? If so, we’d love to hear from you!

Since 1973, The Alex has been a community-based, not-for-profit organization providing integrated primary health care, community support services, and housing-focused programs to individuals and families who experience barriers to accessing traditional health, housing, and social service systems. Services are grounded in principles of health equity, low-barrier access, trauma-informed practice, cultural safety, harm reduction, and person-centered care.

Pathways to Housing operates as an evidence-based Assertive Community Treatment team, adhering to the ACT Fidelity framework and guided by recovery and recovery-oriented supportive housing principles. Through team-based outreach, onsite programming, and access to subsidized housing, the program provides integrated primary care, psychiatric care, mental health services, and social support to participants who have been chronically unhoused and are living with psychotic illness.

Reporting to the Clinical Team Lead, the Social Worker is a key member of the PAO Team and is responsible for utilizing a variety of approaches to support program participants in achieving stability and wellness while reintegrating into the community. Responsive to ACT Team duties, Social Workers offer advocacy, skill development, supportive counselling, referrals, and system navigation, and assist participants in meeting basic and housing needs.

This is a permanent, full-time position.

• Offer culturally supportive services, where indicated.
• Uphold the principles of the ACT Model, Harm Reduction, and Trauma Informed Care.
• Understand and adhere to the Mental Health Act and Community Treatment Orders.
• Understand and follow program policies and procedures.

• Complete regular evidence-based assessment tools with program participants and required data entry.
• Complete, collect, and assist with data collection and entry as directed.
• Create, implement, and update participant-centered treatment plans, service plan goals, and safety planning.
• Complete required documentation and charting with excellence within electronic medical record system, in accordance with agency policy and procedures, and respective of professional college requirements, and relevant legislation.
• Complete team schedule, as required.

• Support program participants who experience acute, severe and persistent mental health and substance use disorders.
• Provide single-staff, assertive outreach services to program participants.
• Connect participants to appropriate services in the community and assist in facilitating referrals as needed.
• Teach, support, and assist participants in their homes and community settings with activities of daily living skills.
• Help identify risk factors that could lead to eviction and work alongside program participants and housing first partner agencies to reduce the likelihood of eviction.
• Accompany and/or provide transportation support to external appointments.
• Advocate for the rights of program participants, upholding their dignity and autonomy.
• Empower participants to be engaged and participate in their care.
• Assist participants with systems navigation, including justice, financial, and health care while maintaining continuity of care.
• Provide services to assist participants with needs such as housing, housing location, entitlements, employment, education, community integration, etc.
• Understand and support participants with medication assistance as required.
• Maintain a comprehensive understanding of the impact of trauma on mental health and addiction issues.
• Work collaboratively with program participants, families, and partner agencies to assist participants in achieving treatment and recovery goals.
• Nurture professional relationships with other service providers to ensure a high quality of service for our participants.
• Complete mental status examinations, risk assessments, and supportive counselling informed by Social Work theory.
• Complete intake assessments, manage the triage list, and facilitate program entry.
• Collaborate with and participate in regular care conferencing/consultation with partner agencies and hospitals.
• Facilitate the Needs and Services Questionnaire as a Housing Strategist.
• Provide ACT services as outlined in participant Community Treatment Orders.
• Provide a provision of psychoeducation within groups, individual visits, partners, and natural supports.
• Complete applications and documents using professional designation.
• Maintain client confidentiality and clear boundaries.

• Actively participate in daily team meetings and treatment planning meetings.
• Demonstrate a strong commitment to the interchangeability and flexibility required of a transdisciplinary ACT…