What is a PCN Social Worker?

The South Island Primary Care Network Social Worker contributes to enhancing the health and well-being of individuals and their families by addressing a range of social, economic, systemic, and psychological concerns. This role is an integral part of the primary care team, focusing on providing comprehensive support to improve overall outcomes.

Role Overview

As part of the primary care team, PCN Social Workers provide support to family physicians and nurse practitioners by:

• Assessing the social determinants of health affecting patients
• Providing culturally safe and trauma-informed care
• Coordinating care and participating in case conferencing
• Offering expertise on applicable legislation to ensure the safe and ethical care of patient

• Direct services to patients:

  • Conducting psycho-social, emotional, and spiritual assessments of health status
  • Delivering brief, solution-focused counseling on issues such as illness, grief, and loss
  • Addressing family and interpersonal relationship concerns
  • Supporting patients with new diagnoses
  • Offering self-management and coping strategies, including problem-solving skills and navigating challenging situations
  • Managing concerns related to abuse and neglect
  • Providing short-term crisis intervention and system navigation support

• Scope of care:

  • Collaborate within a multidisciplinary care team, including family physicians and nurse practitioners, medical office assistants, registered nurses, and mental health and substance use consultants
  • Communicate with the clinical team to update client status, coordinate specialized services, or recommend modifications to treatment and care plans
  • Serve as a resource by offering guidance and demonstrating the value of social work services
  • Engage in quality improvement initiatives and evaluations to enhance service delivery