Intensive Geriatric Service Worker Regional Geriatric Pgrm
3 weeks ago
Intensive Geriatric Service Worker
Description
The IGSW will work with various programs as part of an inter-professional team supporting the care of patients who are affected by physical, mental and social frailty. This role will implement care plans developed in collaboration with older adults and their families by the Specialized Geriatric Services and Geriatric Emergency Nurse in partnership with the Community Care Access Emergency Department Case Manager. The IGSW will assist with the development of an integrated delivery of service through partnerships with agencies providing services for older adults across the health and social care system; provide transition services for older adults with complex specialized geriatric concerns; and ensure that these individuals are able to obtain the services/resources deemed necessary in the identified care plan to live successfully in the community.
Duties and Responsibilities
·Engage people who are unable to access needed resources or services; assist people in addressing immediate needs (e.g. food, medical attention, medications, transportation, and other community-based services)
·Facilitate with the person¿s/family¿s agreement, the involvement of members of the social network in the successful implementation of the older adult¿s individual care plan
·Provides intensive support following the transition from Emergency Department, acute care or ambulatory specialized services; provide direct support to the older adult in accessing, receiving services and/or attending appointments and/or day program
·Assist with coordination and integration of client information across the continuum
·Provide home visits, building on existing documentation, assessments and service plans implement care plan
·Act as a liaison with the community agencies to ensure appropriate client referrals.
·Act as a resource and provide information, guidance, support and consultation to other staff and community care providers in terms of strategies and community resources for their clients.
·Maintain community relationships with key community partners, i.e. Home and Community Care Support Services, mental health, substance use agencies, and social service agencies, primary care service program members.
·Serve as a primary contact for the older adult/family and coordinate services received across the system. If multiple agencies are involved, designate (in collaboration with person/family and other service providers) lead agency for service coordination.
·Collaborate with Specialized Geriatric Services team members and clinicians who made referrals to:
oEnsure that the service plan is implemented as agreed upon.
oEnsure that multi-disciplinary assessments are coordinated and integrated into a single service plan.
·Involve the older adult/family and social network in the monitoring, evaluating, and revising of service goals.
·Facilitate and/or provide agreed upon service to individual, and their family/support network in a variety of contexts (home, office, other community location) depending upon need and the person¿s/family¿s unique circumstances.
·Involve relevant community services, resources, and network members in the provision of treatment and support to the fullest extent possible.
·Develop intervention and support plans that reduce reliance on the formal emergency department and acute care settings
Qualifications
·Graduate of Counselling, Social Service Work, Addictions and Mental Health, Community Service Work, Registered Practical Nurse, gerontology or a related discipline from an accredited post-secondary institution;
·An undergraduate degree in aging or gerontology (considered an asset/preferred)
·A minimum 2 years¿ experience working with older people with medical complexity and experiencing frailty
·Recent experience working in a community role as a case manager or case worker preferred; ability to work collaboratively with formal and informal community resources
·Knowledge base of community-based service principles and modalities and Emergency Department and Alternate Level of Care (ALC) opportunities
·Sound knowledge of inner city populations and community issues and geriatrics/gerontology
·Excellent understanding of the impact of the social determinants of health and a commitment to working collaboratively with patients to mitigate these
·Demonstrates excellent knowledge of recovery model as it applies to frail older adults, mental health and substance use issues
·Demonstrates excellent knowledge, understanding, and skills when using Microsoft office and its related programs including Word, excel, outlook and apps on PC, smart tablet and phone.
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