Social workers break down many complex systems on behalf of clients

March 1, 2021

Social workers and unions have much in common: they tend to see issues through the same lens with a focus on equity, social justice, fairness, economic inclusion and advocacy.

With these themes at play, social workers link many complex issues behind the scenes to ensure that their clients get the access they require to receive the best care and access to service as possible.

“I spend time with my clients during home visits,” notes Sandra Stefaniak, a social worker in the Central East Local Health Integration Network. “The home visit is the first step of the work we do with clients. After the visit, we complete our assessment, initiate services required, provide links to community resources and connect with other system partners, just to name a few.”

For nine years, Stefaniak has worked as a Complex Care Coordinator and collaborates with other care coordinators and system partners to try to solve sometimes multifaceted problems for clients and for the system as a whole.

“My clients may have a whole host of issues that need to be examined and resolved. Some of them are very vulnerable and need help from equity, economic and fairness perspectives. It is my role to advocate on behalf of my clients to ensure they get the help that they need,” she says.

Social workers are integral on the front lines supporting Ontarians who are dealing with various issues including family violence, addictions, caregiver stress, abuse and bullying. Social workers use their unique expertise and skills to identify causes of stress, help with the development of coping skills, find solutions to problems, and connect people with the resources they need. (See sidebar on the right for some of the great work that our Care Coordinators do every day.)

We come to the table to think about the individual’s struggles as perhaps being part of a broader systemic problem. -Sandra Stefaniak, Social Worker

“Social workers are trained to put clients at the centre of everything that we do,” notes Stefaniak. “We come to the table to think about the individual’s struggles as perhaps being part of a broader systemic problem.”

There are many complex systems that clients can face including health care, housing, finance, community care, government structures and more. In addition, social determinants of health such as income, education, job security, health service ability, gender, race and disability play a key role in many clients’ needs.

“My work frequently involves helping our clients understand how these systems work together and finding a path to improve client care and access to resources. There is no question that social determinants can have a significant impact on both client care as well as client outcomes, and they can no longer be left in the background for social workers to address. The systems may need to be revised so that there are fewer barriers for clients. It is my job to identify potential improvements in systems to better my clients’ needs.”

Learning seems to be a two-way street. Not only do Stefaniak’s clients learn from her, she has learned from her clients. "Being a social worker has given me the opportunity to meet and learn from many incredible clients and caregivers who everyday live with all kinds of challenges and adversity and I find these people very inspiring,” she notes.

Given that ONA strongly supports achieving health equity and advocates examining policy issues through a social determinants of health lens, it’s no wonder that social work and unionism can go hand in hand.

This year, we want to spotlight the amazing advocacy of social workers who work as Care Coordinators in the Central East Local Health Integration Network (LHIN). These members successfully organized to ensure social workers were NOT excluded as Care Coordinators under the government’s draft home care regulations. The initial draft stated that only regulated health professionals under the Regulated Health Professions Act would be able to practice as care coordinators.

To learn more about social workers and the amazing work that they do, visit

Social workers hold many Care Coordinator roles within Ontario’s health-care system including:

Children's Care Coordinators help families with children navigate complex health and social conditions to allow children to stay at home with their families and to join their peers at school and in the community.

Hospital Care Coordinators work with patients and their families to help them manage the often-stressful transition from hospital to home to ensure that proper services are in place to support that patient’s continued recovery in their home.

Short Stay Care Coordinators make sure patients in the community have the support necessary to receive health care in their homes. This includes essential services such as I.V. therapy, wound care, rehabilitation, and other community-based health care services

Community Care Coordinators help patients with ongoing and often complex medical needs remain independent in the community. This includes helping families navigate LHIN services and community-based supports as well as working with patients and families to determine when Long Term Care planning should begin.

Placement Care Coordinators help patients and their families navigate the complex Long-Term Care home system to ensure that patients are able to make often difficult and stressful transition from their homes to a Long-Term Care home.

Palliative Care Coordinators work with patients and families to provide emotionally challenging and medically complex support to allow people to receive end of life care in their homes.