Social Worker

The Social Work and Discharge Planning team consists of staff that provide scope of practice social work and discharge planning for all four sites of Halton Healthcare. 

The successful candidate will work within a fast-paced environment as a collaborative team member of an interdisciplinary team. Using critical thinking and working with the interdisciplinary team, the Social Worker collaboratively formulates, facilitates and coordinates discharge plans focused on the needs and goals of the patient and their family system. Provides social work support to patients and families across Maternal/Child, Pediatric, Acute Care, and ICU settings. Responsibilities include, but are not limited to, supporting families experiencing fetal loss, addressing newborn protection concerns, and managing a wide range of psychosocial issues within the adult patient population, including homelessness, financial hardship, mental health concerns, substance use, intimate partner violence, and elder abuse.

• Coordination, formulation/development, documentation, and implementation of care plan for hospital discharge and safe transition back to community or institutional setting.
• Identification of both short and long term goals to ensure/enhance continuity of care for patient/family.
• Ensure plan is communicated to all stakeholders and that appropriate referrals have been processed and received.
• Ensure that patient and/or SDM understands the discharge plan and has the relevant contact information for community partners.
• Ensure efficient use of hospital and community resources
• Early identification of patients requiring complex discharge planning case management through high risk screening criteria, consultation with team members and referrals.
• Planning, review and communication of plans and time lines in partnership with the multidisciplinary team, client/SDM, family, and community agencies/facilities.
• Facilitation of safe patient discharge through: case coordination and development of appropriate discharge plan. Included but not limited to: patient/family education; referral and completion of application to community services; coordination of legal/financial capacity or SDM issues including potential PGT involvement.
• Advocate to identify gaps in services, need for individualized program consideration and system level changes required to meet changing needs of patient population.