Community Care Coordination Support Worker

4 weeks ago

Toronto, Canada Inner City Family Health Team Full time

**Background**:
The Care Coordinator will play a central role in providing comprehensive and compassionate care to individuals experiencing homelessness. This position involves coordinating health services, facilitating access to care, service navigation, referrals, advocacy and accompaniments. The Care Coordinator will work closely with healthcare providers, social workers, community organizations, and the patients themselves to build a collaborative circle of care, establish a coordinated care plan, and monitor for progress and accountability. Address both immediate healthcare needs and long-term wellness goals, ensuring continuity of care for this vulnerable population.

**Roles and Responsibilities**:

- Working collaboratively and developing strong partnerships with external service providers, such as withdrawal management services, hospitals, law enforcement agencies, and housing providers.
- Providing information, referrals, service navigation to clients of ICFHT
- Working with participants to identify and achieve self-directed goals.
- Connecting clients with supports in the community based on their needs which will help them achieve and maintain stability, including support groups, life skills groups and social events.
- Serve as the central point of contact for the healthcare team, including doctors, nurses, social workers, and external service providers.
- Participate in multidisciplinary team meetings to discuss patient care strategies and updates.
- Develop, implement, and monitor individualized care plans that address medical, psychological, and social needs.
- Support the intake process through assessment, coordination and service integration.
- Facilitate referrals to appropriate healthcare services, including primary care, mental health, substance use treatment, and specialty care.
- Act as an advocate for patients to ensure they receive timely and appropriate care.
- Maintain clear, accurate, and timely documentation of patient interactions and care plans in the clinic’s electronic health records system.
- Maintaining ongoing support in the community, including home visits, office visits, accompaniments to appointments, and meetings in institutional settings.
- Build trusting relationships with patients, emphasizing a non-judgmental, empathetic approach.
- Facilitate patient follow-up visits and monitor adherence to treatment plans.

**Qualifications**
- Degree or diploma in social work, community/social services or a combination of education and experience.
- 2 years of direct experience in a healthcare, social services, or case management role.
- Experience working with homeless or underserved populations.
- Experience in a primary care or community health setting is highly desirable.
- Strong organizational and time management skills.
- Excellent communication and interpersonal skills, with the ability to work effectively with diverse populations.
- Experience, alignment and commitment to harm reduction principles and practice.
- Strong understanding of and commitment to harm reduction, trauma-informed, anti-oppression, anti-racist, and trans-inclusive practices.
- Ability to work independently as well as in a team environment.
- Highly motivated self-starter and initiative taker.
- Proficiency in computers, including Microsoft 360 (Work, Excel, Teams), EMR and Case Management software

We strongly encourage applicants who reflect Toronto’s Indigenous, black and culturally diverse communities to apply.
- We thank all applicants for their interest in this position; however, we will only be contacting those selected for an interview._
- We are pleased to accommodate job applicants' individual needs throughout the recruitment and selection process in accordance with the Ontario Human Rights Code and the Accessibility of Ontarians with Disabilities Act, 2005 (AODA). If you require accommodation at any time during the recruitment process, please speak with the Clinical Manager._

**Job Types**: Full-time, Fixed term contract
Contract length: 5 months

Pay: $52,707.00-$61,079.00 per year

Work Location: In person

Application deadline: 2024-11-22

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