Social Worker - Integrated Comprehensive Care Program

Social Worker – Integrated Comprehensive Care

• This position requires traveling within Hamilton, Burlington, Brantford, Niagara regions and Norfolk county. Union:
  Non-union Hours of Work:
  Days 8 am-4 pm
• Average 37.5 hours bi-weekly Posting Date:
  August 6, 2026 Closing Date:
  Until Filled Wages: $22.98 - $50.62 per hour

The Social Worker - ICCP (SW-ICCP) program will provide psychosocial assessment, counselling/psychotherapy, case management, Patient/family education, supportive care, discharge planning, service coordination and consultation according to best practice standards in order to assist the client in achieving optimum recovery and quality of life.

This role supports Sr. Manager - ICCP in the efficient and effective operations of the program activities, as well as providing leadership in high-risk social situations, program development, advocacy and developing and maintaining strong community linkages. Registered Social Workers will also participate in mentoring community development, teaching, continuous quality improvement and research activities.

Clients are typically individuals who have been discharged from hospital to their own home, but who still require some clinical care for a short period of time. These clients are in process of having long-term care needs assessed, are medically stable, can be of any adult age group, and may require mechanical or 2-person lifts. Clients can have variable care plan timelines.

• Maintains current working knowledge of relevant legislation in Mental Health Act, Health Care Consent Act, Substitute Decisions Act, Public Hospitals Act, Long Term Care Act, Child and Family Services Act, PHIPA and Excellent Care for All Act
• Maintains expertise in generic social work practice and implements evidence-based practice which includes family/individual and group treatment modalities, case management, crisis intervention and discharge planning
• Documents all patient related interventions adhering to the OCSWSSW Standards of Practice and the RSW disciple-specific documentation guidelines
• Completes some virtual care visits as per client care plans require
• Conducts comprehensive psychosocial assessments from a systems perspective which will include contact information (POA, SDM, NOK), current family/social status, financial situation, community agency involvement, mental health status, psychosocial history, social work analysis, identified issues goals and intervention plans
• Identifies and intervenes with high-risk social work analysis, identified issues, goal and intervention plans
• Identifies and intervenes with high-risk social situations such as intimate Partner Violence, Child Abuse/Neglect, Elder Abuse/Neglect, Financial Abuse, and others as appropriate utilizing best practise social work guidelines
• Provides theory-based counselling which may include crisis intervention and illness adjustment counselling
• Provides case management for an assigned client area including the facilitation of client and team goals related to function and discharge, connecting the client and/or family with services and/or resources in the community and ensuring patients and families understand the plan of care post discharge
• Coordinated all complex discharges and facilitates program specific case management activities
• Assumes the lead responsibility for discharge planning including the identification of client and family needs and resources related to safe patient discharges
• Provides mentorship around specific developed areas of expertise to new RSW staff and healthcare providers of other disciplines
• Meets the requirements of Ontario Social Work re-certification through continuing education as outlined by the OCSWSSW
• Complies with all required Workload Measurements and other statistical data collection expectations
• Engages in knowledgeable, sensitive and expert care of seniors, and support of their families
• Advocates in the best interests of the clients
• Completed regular, mandatory and optional professional development
• Engages in self reflection and adaptation to the changing needs of clients

• Working with others in ordering of required supplies and/or equipment
• Recording treatment activities in client charts, maintaining on-ongoing support of other interdisciplinary program staff
• Developing and presenting reports and/or metrics as requested
• Supporting clients in setting up therapy appointments
• Supporting referral/intake processes of the program
• Providing general assistants to program Managers
• Performing general administrative duties related to the role
• Participate on committees and program development related to areas of practice.

• Regularly demonstrates our mission, vision and values:
  • Support compassionate care, faith and diversity
  • Deliver quality care, pursue and share knowledge, respect diversity, remain faithful
  • Commit to working everyday with dignity, respect, service, justice, responsibility and enquiry
• Ability to work cooperatively with…