Outreach Worker

The Centre for Family Medicine
Term (Duration): 
The KW4 Community Ward-In Home (CWT) is an inter-professional team that delivers in-home primary care to complex patients in the Kitchener-Waterloo-Wellesley-Wilmot-Woolwich (KW4) area, including those who:
- have complex chronic conditions
- are living with mental health, psychosocial and/or addictions challenges
- are very frail or have frequent falls
- are not managing well, or are not getting the care and support they need
- are visiting the ER or being hospitalized frequently
- cannot get to regular office appointments for whatever reason

Our team currently consists of part-time nurse practitioners, two outreach workers, a social worker, a chiropractor/mobility specialist, a pharmacist, a consulting physician, a registered nurse, and a team-assistant. While the team is primarily an in-home team, it operates a supporting clinic, limited in scope, for a sub-set of its patients. In addition, it works collaboratively with other community partners including supporting clinics operating in several community locations.

Position Overview
The Outreach Worker is a key position on the team whose role is to support care delivered to patients in their homes with a strong emphasis on social determinants of health. This may include case management, system
navigation, visiting patients, developing and supporting the implementation of care plans, and accompanying patients to appointments. The Outreach Worker requires initiative and passion in caring for our patient population. The role and responsibilities will evolve and develop over time, along with the Team.

Additional Responsibilities

Team Participation
- Works as both a lead and case management support to other team members working with specific
patients (18+)
- Participates in discussions, gap-analyses, problem solving, and decision-making at weekly Team
- Ensures that the Team and other stakeholders are kept informed about developments and new and
existing patient challenges as necessary
- Consults with other team members who have different or enhanced areas of expertise

Patient Care
- Listens to patients to identify their social, physical and emotional needs
- Builds on existing resources and connects patients to additional resources to create a support network
- Advocates for services as necessary
- Visits patients on behalf of other team members and accompanies patients to appointments (for example
specialists, community services etc.)
- Negotiates with other care providers about how service is provided to ensure patient participation in
their own care
- Follows all safety protocols while working with residents in their home and community

Documentation and Records Management
- Participates in the development of coordinated care plans (CCPs)
- Documents and maintains clear records in an EMR of each patient visit including supports, services and gaps
- Provides clear and timely communication with other healthcare and social service providers
- Other correspondence as required

Qualifications and Experience:
- 3 years of experience, preferably working with complex patients
- Preferred experience or education in community or primary health care and an adult specialty
- Demonstrated ability to work collaboratively with Allied Health Professionals
- Demonstrated excellence in clinical judgment, health assessment and therapeutic skills
- Demonstrated experience in social determinants of health
- Proven relationship building and problem-solving skills
- Proven ability to keep confidential information regarding patients, health care providers, employees, business operations and team information
- Demonstrated ability to listen effectively and to build working relationships with patients, and other team members
- Computer knowledge of email, voicemail as well as computer literacy
- Access to a reliable vehicle and a valid Ontario driver's license are required
- Certification in mental health, addictions, geriatrics, and/or counselling are all assets
Date Posted: 
Fri, Apr 5 2019
Job Location: 
How to Apply: 
At the Centre for Family Medicine we strive to offer an exciting and caring work environment.

If this position is of interest to you please send your letter of interest and your Curricula Vitae by Monday April 22nd to: Human Resources, The Centre for Family Medicine FHT HR@family-medicine.ca

The Centre for Family Medicine Family Health team is a respectful and inclusive workplace. Upon individual request, hiring processes
will be modified to remove barriers to accommodate those with disabilities. Should any applicant require accommodation through
the application, interview or selection processes, please contact Human Resources at hr@family-medicine.ca for assistance
Mon, Apr 22 2019
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