Comprehensive Care Specialist (2024-431-CC)

About this position

Competition: (2024-431-CC): Comprehensive Care Specialist (2024-431-CC)

Employment Type: Permanent full-time, Bargaining Unit (1 Vacancy)

Work Hours: 37.5 hours: Monday - Friday, 9am - 5pm

Work Setting: Onsite – Limited Opportunities to Work Remotely

Salary: 
External Rate: $66,693.11
Internal Rate: 68,054.19

Application Deadline: November 18, 2024, by 11:59 pm

A. GENERAL ACCOUNTABILITY

This position is accountable to the Supervisor support to the clients referred to the Comprehensive Care and Integration (CCI) Specialist team. The incumbent is responsible for supporting transitions from hospital to community for individuals living with complex mental health, addictions, and health needs, and psychogeriatric concerns. The CCI specialist provides clients with short term case management, attachment to primary care as needed and develops a coordinated care plan (CCP).

This position supports the unit’s goal of helping individuals who may be experiencing issues around dementia, mobility concerns, mental health and/or addictions, challenging behaviours, and those living on low incomes within an anti-oppressive, trauma-informed, harm reduction and mental health recovery framework.

This philosophy of this work is in keeping with WoodGreen’s mission to deliver services that enhance self-sufficiency, promote well-being and reduce poverty through innovative solutions to critical social needs.

B. NATURE AND SCOPE

The Comprehensive Care Specialist is responsible for working independently and with the Comprehensive Care and Integration Specialist (CCIS) team to facilitate smooth care transitions (i.e. from acute care to community), to provide service coordination, psycho-social assessment, intensive case management, therapeutic and/or supportive counselling, and making referrals to various resources to improve outcomes for older adults, seniors and/or their family/caregivers.

The role includes collaborating with health care providers, and other resources in the community to enable individuals who are vulnerable, at risk and marginalized to live safely and independently in the community and reduce unnecessary hospitalizations and emergency room use.

C. SPECIFIC RESPONSIBILITIES

• Referrals and Outreach:
• Develop trust and rapport with clients and hospital staff in order to identify individuals who could benefit from social work support and transitional care coordination.
• Work with hospital staff to identify and engage clients and support hospital staff in making referrals to the CCIS team, as appropriate.
• When necessary, follow up with referral source(s) to learn more about the client being referred, reason for hospitalization and/or reason for referral, to support in development of Coordinated Care Plan (CCP).
• Develop relationships with other service providers in order to make seamless, effective referrals and service connections.
• Work closely with CCU central intake and program managers to identify clients with frequent hospital/ED use who may benefit from CCIS support to reduce unnecessary hospital use.

• Perform psychosocial and/or psychological and geriatric assessments.
• Provide service/care co-ordination, system navigation, short-term and long-term planning and follow-up support. Provide short-term case management services (up to 90 days) to clients through the development and implementation of a care plan and/or Coordinated Care Plan (CCP) to address their priority and emerging needs. Provide short-term intensive care coordination and work closely with the CCIS team, hospitals, and other referral sources to support clients and facilitate smooth transitions between hospital and community.
• Provide clinical and/or supportive counseling to clients utilizing a wide range of therapeutic approaches that best meet the clients’ needs and circumstances.
• Provide preliminary assessment of risk in crisis situations, consult and devise an intervention and action plan, and provide crisis intervention.
• Provide crisis intervention and practical assistance to clients and/or family or caregivers as required in homes and community settings.
• Link clients with internal resources, program and services within Community Care Unit and WoodGreen as well as with external resources and programs.
• Work to prevent future avoidable ED visits, 30-day hospital re-admission and Alternative Level of Care (ALC) placements for clients referred to the CCIS team.
• Facilitate access to service including arranging for phone/in-person interpretation when needed.
• In consultation with internal and external partners, develop appropriate onsite programming and supports. Facilitate or lead social and/or support groups as required.
• Comprehensive Care and Integration Specialist Team Member
• Provide suggestions, support and resources to other CCI specialists and participate actively as part of the CCIS team, sharing expertise
• Participate in Team Calls, and manage all referrals accepted, including data collection/tracking
• Discuss options for expanding referral sources while balancing CCIS capacity, operational issues and offer recommendation to continue to develop Hub model

• Ensure the organization’s policies and procedures are carried out.
• Ensure excellent communication with other staff who work on-site at the various specified locations, including PSWs, housing workers, Supervisors and other partners in the community.
• Keep current about the range of services available in other agencies.
• Provide mentorship, training and/or supervision to student placements and volunteers.
• Participate in team and unit meetings regularly, and promote the healthy functioning of the team and unit.
• Participate in ongoing training and education.
• Participate in supervision sessions and annual performance appraisals with program manager.
• Maintain appropriate records and documentation in a timely manner and collect statistical data required for the accountability of the program.
• Represent the unit on internal and/or external staff committees as directed by program manager.
• Perform other duties as assigned.

• Minimum of 3 years related experience in mental health, addictions, and/or social work. Demonstrated experience facilitating psycho-social 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 is required.
• Experience in conflict mediation, client engagement and community development is required.

• Demonstrated ability in supporting individuals who have complex mental health and/or addiction issues, geriatric issues, cognitive impairment, history of trauma, violence/abuse, chronic physical health issues, etc.
• 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 all service providers and stakeholders.
• Excellent organizational and time management skills.
• Excellent oral and written communication skills and documentation skills.
• Self-directed and independent, but also proven experience in working effectively as a team member in collaboration with other community professionals.
• Ability to exercise good judgment and flexibility.
• Ability to work from a client-centred 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 determinant of health.
• Applied computer skills (MS word, Excel, Internet) and ability to use client information systems.
• Training and experience using InterRAI suite, Pirouette and ConnectingOntario is an asset.
• Proficiency in second language, written and oral, is a strong asset.
• Due to WoodGreen’s multi-site locations we reserve the right to relocate the incumbent to another site, in the same position performing the same duties, as may be dictated by program needs. Reasonable notice of such site relocation will be given.
• Capable of fulfilling the physical and psychological demands of the job as per the attached Position Demands Analysis.
• Accommodations for disabilities provided upon request.