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About the Role

The Comprehensive Care Specialist facilitates smooth care transitions, provides service coordination, psycho-social assessment, intensive case management, therapeutic/supportive counseling, and referrals for older adults, seniors, and their families/caregivers. This role involves collaborating with healthcare providers and community resources to help vulnerable individuals live safely and independently, reducing hospitalizations and emergency room use.

Responsibilities

Develop trust and rapport with clients and hospital staff to identify individuals benefiting from social work support and transitional care coordination.
Collaborate with hospital staff to identify and engage clients, and support them in making referrals to the CCIS team.
Follow up with referral sources to gather client information for Coordinated Care Plan (CCP) development.
Develop relationships with service providers for seamless referrals and service connections.
Collaborate with CCU central intake and program managers to identify clients with frequent hospital/ED use for CCIS support.
Perform psychosocial, psychological, and geriatric assessments.
Provide service/care coordination, system navigation, short-term and long-term planning, and follow-up support.
Offer short-term case management services (up to 90 days) by developing and implementing care plans to address client needs.
Provide short-term intensive care coordination and collaborate with the CCIS team, hospitals, and referral sources to support clients and facilitate transitions.
Provide clinical and/or supportive counseling using various therapeutic approaches.
Assess risk in crisis situations, consult, devise intervention plans, and provide crisis intervention.
Provide crisis intervention and practical assistance to clients and/or families/caregivers in homes and community settings.
Connect clients with internal and external resources, programs, and services.
Work to prevent avoidable ED visits, 30-day hospital re-admissions, and Alternative Level of Care (ALC) placements.
Facilitate access to services, including arranging for interpretation when needed.
Develop appropriate onsite programming and supports in consultation with partners.
Facilitate or lead social and/or support groups.
Provide suggestions, support, and resources to other CCI specialists and actively participate in the CCIS team.
Participate in team calls and manage all accepted referrals, including data collection and tracking.
Discuss options for expanding referral sources while balancing CCIS capacity and operational issues.
Ensure adherence to organizational policies and procedures.
Maintain excellent communication with on-site staff and community partners.
Stay current on available services from other agencies.
Provide mentorship, training, and/or supervision to student placements and volunteers.
Participate regularly in team and unit meetings.
Engage in ongoing training and education.
Participate in supervision sessions and annual performance appraisals.
Maintain appropriate records and documentation in a timely manner and collect statistical data.
Represent the unit on internal and/or external staff committees.
Perform other duties as assigned.

Requirements

Masters of Social Work or post-graduate degree in a relevant field with 2+ years of extensive crisis/complex seniors experience OR BSW with 5+ years of extensive crisis/complex/seniors experience.
Registration in good standing with the Ontario College of Social workers and Social Service Workers or another relevant regulatory body in Ontario (e.g., CPRO or COTO).
Minimum of 3 years related experience in mental health, addictions, and/or social work.
Demonstrated experience facilitating psychosocial groups and supporting individuals with significant mental health and/or addictions issues, cognitive impairment (e.g., dementia), and chronic health issues from a harm reduction, trauma-informed, and mental health recovery approach.
Experience in conflict mediation, client engagement, and community development.
Demonstrated ability in supporting individuals with complex mental health and/or addiction issues, geriatric issues, cognitive impairment, history of trauma, violence/abuse, chronic physical health issues.
Proven working knowledge of theories of addiction, evidence-based treatment models, and best practice approaches.
Knowledge of, experience with, and demonstrated ability in providing therapeutic and supportive counseling.
Knowledge and experience providing addictions counseling and support.
Proven ability in providing intensive and short-term case management, care coordination, and system navigation.
Strong assessment skills.
Strong de-escalation and crisis intervention skills.
Strong interpersonal and conflict resolution skills to work collaboratively with service providers and stakeholders.
Excellent organizational and time management skills.
Excellent oral and written communication and documentation skills.
Self-directed and independent, with proven experience working effectively as a team member.
Ability to exercise good judgment and flexibility.
Ability to work from a client-centered approach.
Comprehensive understanding and knowledge of the mental health, addictions, geriatrics, health sector, and community resources.
Demonstrate knowledge of issues affecting marginalized communities, policies, legislation, programs, and other issues related to scope of practice and social determinants of health.
Applied computer skills (MS Word, Excel, Internet) and ability to use client information systems.
Capable of fulfilling the physical and psychological demands of the job.
Accommodations for disabilities provided upon request.

Skills

Transitional care coordination
Service coordination
Psycho-social assessment
Intensive case management
Therapeutic counseling
Supportive counseling
Referral making
Collaboration with healthcare providers
Community resource navigation
Conflict mediation
Client engagement
Community development
Harm reduction approach
Trauma-informed approach
Mental health recovery approach
Addictions counseling
System navigation
Assessment
De-escalation
Crisis intervention
Interpersonal skills
Conflict resolution
Organizational skills
Time management
Oral communication
Written communication
Documentation
Teamwork
Client-centered approach
MS Word
Excel
Internet
Client information systems

Location

Onsite

Work Type

Casual
Full-time

Experience Level

2+ years of extensive crisis/complex seniors experience
5+ years of extensive crisis/complex/seniors experience
Minimum of 3 years related experience in mental health, addictions, and/or social work

Education Level

Masters of Social Work
Post-graduate degree in a relevant field
BSW

Salary/Compensations

$31.98/hour

Benefits

Accommodations for disabilities provided upon request.

About the Company

WoodGreen is an equal opportunity employer.
This public job posting uses AI-powered tools to screen, assess, or select applicants.

Equal Opportunity

We are committed to providing an inclusive and barrier-free selection process and work environment.
If contacted in relation to an employment opportunity, please advise our People & Culture representatives at careers@woodgreen.org of the accommodation measures required.
Information received relating to accommodation will be addressed confidentially.