Complex Care Coordinator

7 months ago

Toronto, Canada Sinai Health Full time

Sinai Health is a leading academic health science centre with a provincial, national and international reputation for discovering and delivering life-changing care. We provide excellent and compassionate care in hospital, community and home. Comprised of Mount Sinai Hospital, Hennick Bridgepoint Hospital, the Lunenfeld-Tanenbaum Research Institute and our system partner Circle of Care, we translate scientific breakthroughs, push boundaries for health solutions, and educates future clinical and scientific leaders.

To support us on our journey, Sinai Health is looking for a Complex Care Coordinator (CCC)/Social Worker to support our Mount Sinai Academic Family Health Team (MSAFHT).

The CCC/Social Worker is a health care professional who works with patients in the Academic Family Health Team who have been identified as requiring assistance to ensure that health care needs are met and that the journey of the patient through the health and community sectors are seamless and integrated.

**Responsibilities**:

- Finds resources required by patients and family members in order to make informed decisions about his/her own health
- Provides referrals to services to assist patients to resolve and address their social and personal problems
- Liaises with community agencies or partners, and identify additional or alternative services and provide referrals
- Assists patients to sort out options and develop plans of action while providing necessary support and assistance
- Assists patients in locating and utilizing community resources including legal, medical and financial assistance, housing, employment, transportation, assistance with moves, day care and other referral services
- Participates in the selection and admission of patients to appropriate programs (in consult with community programming)
- Assesses and investigate eligibility for social benefit
- Meets with patients to assess their progress, give support and discuss any difficulties or problems
- Refers patients to other social services
- Advises and aids recipients of social assistance and pensions
- Implements and organizes the delivery of specific services within the community
- Maintains contact with other social service agencies and health care providers involved with patients to provide information and obtain feedback on patients' overall progress
- Ensures that the patient journey from the acute/tertiary sector to primary/community care is as seamless as possible by making certain all follow up appointments are booked and linkages to home and community care are made prior to or just shortly after the patient is discharged from hospital
- Completes coordinated care plans with patients where appropriate
- Attends relevant LHIN meetings as directed by the Director
- Other duties as required to fulfill the functions of the position
- Job Requirements- Successful completion of a Master’s degree in Social Work from an accredited educational institution
- Registration in good standing, with the Ontario College of Social Workers and Social Service Workers required
- Three years of experience, including community care
- Good knowledge and understanding of primary health care and chronic disease prevention and management, preferably in a community-based setting
- Expert knowledge of community resources and proven referral practices.
- Solid understanding of multidisciplinary, interdisciplinary and interprofessional approaches
- Demonstrated experience leading and facilitating effective team planning
- Demonstrated knowledge of current theoretical frameworks and social work practice standards
- Competence with Microsoft Office suite of software
- Experience with clinical management system (CMS), preferably Practice Solutions’ Suite
- Exceptional organizational skills
- Excellent interpersonal and oral/written communication skills
- Strong problem solving and analytical skills
- Ability to maintain confidentiality, impartiality and good judgement
- High degree of accuracy and attention to detail
- Proven participatory work style, ability to work independently and with a team (e.g. ability to work effectively with all members of the health care team)
- Ability to prioritize, manage time effectively and be flexible in a fast paced and dynamic work environment
- Demonstrated satisfactory attendance and work performance

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