Social Worker, Overdose Outreach Team; OOT

Position: 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…