Fraser Health is the second largest health system in Canada with over 45,000 staff, medical staff and volunteers, and is the largest of five regional health authorities in British Columbia, providing hospital and community-based health services to nearly 2 million people in Metro Vancouver and the Fraser Valley.

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In accordance with Fraser Health''s Vision, Mission and Values, program mandates and clinical practice guidelines, with an emphasis on recovery and rehabilitation and reducing barriers to re-enter the system of care, supports individuals and families with and affected by acute/episodic mental illness and substance use disorders. Focuses on provision of advocacy, supportive counselling, psycho-education, community resourcing, and care coordination support within the local service area across the care continuum, to ensure delivery of consistent, relevant and timely treatment, rapid re-engagement, and access to information where appropriate and feasible. Contributes to the development of programs and provides education within the assigned program. Services may be provided on an outreach basis when required in order to assess and/or engage with clients within their own environment and community.

As a clinician in a shared-team model, provides intake, screening, and assessment services, treatment recommendations and plans, determines referral needs, provides follow-up support, group education, liaison with community resources for specialized services, counsels clients, provides outreach as required, and is assigned as the most responsible clinician to specific clients dependent on the client's primary needs. Provides client and family-centered care through a trauma-informed approach and evidence-informed practice. Encourages knowledge exchange in day-to day activities, empowers clients and natural supports to engage and connect within their communities, and ensures they are supported in navigating the health care system.

1. Develops and implements recovery-oriented treatment options and plans in collaboration with clients and natural supports; provides comprehensive case consultation and follow-up support on treatment decisions in collaboration with other interdisciplinary team members; supports the development/maintenance of abilities related to activities of daily living, discharge and transition of care. Updates the Clinical Coordinator on the status of client treatment and progress, as well as significant and unusual issues, developments, and circumstances.
2. Provides individual, group, and family support, using a variety of interviewing, supportive counseling, and assessment methods. Shares responsibility amongst the team for distributed workload to manage cases, formulate recovery plans and goals, crisis intervention, assist with home visits, run groups, and outreach to clients as required.
3. Supports the intake process and assesses client needs by gathering client information/history via phone interviews or other methods; seeking additional background information to perform initial assessment of client mental health and substance use status and risk to themselves or others and to determine priority of care, client eligibility, availability of resources, service priorities and type of level of care required; collaborating with the interdisciplinary team to determine best approach to care, and assessing the need for emergent crisis intervention.
4. Facilitates client utilization of appropriate community services and rehabilitative programs through activities such as by researching and liaising with available services, and program providers, reviewing type and level of care required which may include assisting clients with their housing needs/arrangements, providing advice and consultation to clients and providing referrals to appropriate community treatment alternatives and services such as family therapy, marital and separation counseling, substance use treatment, victim assistance, employee assistance programs, clubhouses, transition homes, vocational programs, and others, and completes necessary referrals and forms. Utilizes available community resources such as volunteers, community groups, alternate care services and other service agencies in order to develop supportive and rehabilitative programs for adults and their families.
5. Advocates on behalf of clients, by providing clients with information about appeal processes, providing information about clients to relevant Ministries and assisting clients to complete forms; acts as a resource for clients and their families.
6. Makes necessary arrangements for clients to be admitted to hospital when required, including on an involuntary basis, by acquiring background information, making initial assessments, ensuring completion of appropriate forms, and making necessary phone calls to appropriate parties, including general practitioners, psychiatrists and the police; makes transportation arrangements, including providing clients transportation to the hospital as required.
7. Provides client care linkages between community mental health & substance use services and acute care facilities, to facilitate assessment and care planning for client discharge from hospital; liaises with forensic programs; exchanges relevant client information and receives information about the status and background of clients who will be discharged or referred, in order to make necessary preparations for provision of a smooth continuum of care between acute care and community mental health & substance use services.
8. Provides individual and group sessions, including psycho-education or skill development groups, to clients and families with complex needs. Facilitates family and lived experience involvement activities such as client and family information sessions in order to promote knowledge exchange. Provides education to staff, clients, and their families regarding the impact of illness and functional capabilities.
9. Maintains client records by recording information such as client assessments, charting client information via PARIS and/or other clinical information systems, preparing progress notes and reports in accordance with established standards, policies and procedures to meet regulatory requirements, documenting for future reference and ensuring that access to and disclosure of information and records are in accordance with the Freedom of Information Act.
10. Provides follow-up care and services as required, including providing referrals to other healthcare professionals, such as vocational counsellors, recreational therapists, occupational therapists, and psychiatrists.
11. Participates in quality improvement and risk management activities for assigned area by participating in quality initiatives, providing feedback to the Clinical Coordinator about needs and gaps in programs and services and suggesting solutions and initiatives to assist in the development and maintenance of a coordinated mental health & substance use care system within the community.
12. Participates in ongoing education to maintain current and relevant practice, including clinical education, as well as maintaining current knowledge of Federal and Provincial legislation and amendments that impact mental health & substance use client care and service delivery.
13. Participates as a member of local committees and advisory boards to provide and receive information as a representative of the team, as required. Informs regional staff, community groups, and agencies of the role and function of the team by providing information informally and formally during in-services.
14. Participates in clinical research and program evaluation activities relevant to the needs of clients, families, hospitals, and the community, by providing information as requested.
15. Performs other related duties as assigned.

Bachelor's degree in Social Work, Clinical Counselling or other relevant health related discipline. Two (2) years' recent, related experience working with clients and families with, or affected by, mental illness and substance use disorders, or an equivalent combination of education, training, and experience.

Eligible for registration or membership with applicable professional association or regulatory body.

Valid Class V BC Driver's License and access to personal vehicle for business-related purposes.

• Demonstrated client assessment and case management skills.
• Ability to communicate effectively, both verbally and in writing, including empathic and respectful communication appropriate to the situation.
• Good interpersonal skills, including the ability to get along well with clients, families, and members of the interdisciplinary team, and including the ability to effectively network with other services and agencies.
• Ability to set priorities, organize work to effectively manage a heavy and demanding caseload, and exercise sound judgment, both clinically and non-clinically.
• Ability to work effectively and to flexibly manage changing caseload needs under pressure, and during times of change.
• Ability to work independently with minimal supervision, while seeking the appropriate level of consultation and approval from the Coordinator.
• Ability to maintain appropriate confidentiality in accordance with applicable regional policies.
• Ability to quickly learn new methodologies, ideas, and concepts.
• Ability to provide effective and efficient service, while meeting clinical and administrative government and health region policies, standards, and protocol requirements.
• Knowledge of community resources and methods of accessing them.
• Comprehensive knowledge of emergency triage procedures, mental health status assessment, and counseling principles and interview techniques.
• Working knowledge of psychopharmacology, crisis theory, and de-escalation techniques.
• Working knowledge of DSM V Multiaxial Diagnosis or International Classification of Diseases.
• Physical ability to carry out the duties of the position.