Location:  City of Lakes Family Health Team has 4 sites throughout the region including sites at: Sudbury, Val Caron, Chelmsford and Walden.  Home base TBD, but regular visits to the other sites are required.   

Are you a compassionate and resourceful Social Worker looking to make a meaningful impact in primary care?

Join the City of Lakes Family Health Team, where you’ll be part of a dynamic interprofessional team dedicated to collaboration, innovation, and delivering exceptional patient-centered care.

Why Join Us?

CoLFHT delivers comprehensive, team-based primary care designed to support our patients.  As a Social Worker / Patient Navigator, you’ll play a vital role in helping individuals and families navigate complex systems, access essential resources, and build the skills they need to thrive.

This is a unique opportunity to lead impactful programs, advocate for vulnerable populations, and contribute to the health and well-being of our community. If you're passionate about equity, mental health, and system navigation, we’d love to hear from you.

Responsibilities:

Social Workers are a key part of the patient care circle and should be comfortable working to their full scope of practice. As a Social Worker with our team, in collaboration with the primary care provider and an interprofessional care team, you will:

 Mental Health & Psychosocial Support

• Provide brief assessments and therapeutic interventions
• Proficient in assessment, psychotherapy and psychological counseling techniques for working with individuals, couples, families and communities
• Support patients through counseling, education, and outreach
• Demonstrated ability to form and maintain helping relationships with patients. • Working knowledge of the Mental Health Act, Healthcare Consent Act, Substitute Decisions Act and community mental health resources;
• Collaborate with patients to set goals and monitor progress
• Conduct home visits and community outreach
• Identify and report cases of child abuse or neglect
• Participate in case reviews and team discussions
• Educate patients, families, and staff on psychosocial health and prevention strategies
• Maintain clear, confidential documentation
• Stay current with best practices and share knowledge with the team
• Create and support pathways that facilitate the social worker working to their full scope of practice
• Ability to work effectively as part of an interdisciplinary team

Patient Navigation & Advocacy

• Lead the development of our Patient Navigator program
• Help patients access community and social services
• Build and maintain a resource database
• Advocate on behalf of patients with external agencies
• Strengthen communication between community partners and our care team

• Assist patients with accessing financial supports, housing, legal aid, and social services
• Facilitate self-help sessions on banking, taxes, and navigating forms
• Assist patients if required in filling out any forms or applications to support patient navigation or related to the social determinants of health
• Build capacity among providers to identify and support patient navigation
• Support in the creation and implementation of a social prescribing program

Program Development & Evaluation

• Develop tools and guidelines to support best practices
• Collaborate with our Quality Improvement team to measure impact
• Enhance EMR functionality to support navigation and tracking
• Participate in data collection and program evaluation

What We Offer

• A supportive, inclusive, and forward-thinking work environment
• A collaborative team culture that fosters learning, innovation and a shared purpose
• Opportunities for professional growth, leadership, and continuing education
• A chance to make a lasting impact in the Greater Sudbury community

Qualifications

• Bachelor’s degree in Social Work from an accredited institution
• Minimum 3 years of relevant experience
• Registered and in good standing with the Ontario College of Social Workers and Social Service Workers
• Experienced in social work interventions and strategies to assist clients or families to achieve optimum psychosocial and social functioning
• Working knowledge of the Mental Health Act, Healthcare Consent Act, Substitute Decisions Act and community mental health resources
• Experience in providing one-on-one supports to individuals with diversity in income, education, ability, and mental health status
• Excellent verbal and written communication. Listening, organizational, multi-tasking and problem-solving skills. 
• Demonstrated commitment to and knowledge of community-based resources
• Demonstrable knowledge of financial matters affecting low-income people, including income security programs and policies, tax systems, access to financial services, and other income support programs such as WSIB and private insurance companies.
• Previous experience brokering social support services between agencies
• Experience in the development of educational materials for health providers and patients
• Experience with data collection, research and quality improvement
• Experience with a electronic medical records system is an asset
• Demonstrated ability to work effectively in a multi-disciplinary team environment
• Bilingual in French and English considered an asset

 Please forward your cover letter and resume to Meghan Peters, Executive Director of the City of Lakes Family Health Team.  This email address is being protected from spambots. You need JavaScript enabled to view it.

While we thank all applicants, only those under consideration will be contacted for an interview.

We are an equal opportunity employer and we celebrate diversity and are committed to creating an inclusive environment for all employees!