Homeless Outreach Counsellor Regional Geriatric

The Geriatric Medicine Inner-city Outreach Counsellor works closely with the geriatrician, community partners (e.g. Inner City Health Associates and WoodGreen) and clients to support inner-city older adults.

The Outreach Counsellor is responsible for scheduling outreach visits with the geriatrician, time-limited case management, outreach support, and community liaison for older adults. The position will connect with patients referred to the Geriatric Outreach program at St. Michael¿s Hospital, and will support patients to assist them in following their care plan and connect to long-term supports.

**DUTIES & RESPONSIBILITIES**:
- Triaging referrals to the program, and manages registering and scheduling of visits with geriatrician, including follow-up visits- Performs other administrative duties including faxing referrals and forms, keeping patient charts up to date, tracking and managing referrals and investigations for patients and providing appointment details to patients- Ensures results and documentation are reviewed by geriatrician and stored in charts- Reviews geriatric medicine treatment plans with the geriatrician- Establishes and maintains therapeutic rapport with clients to facilitate commitment to adhering to treatment plans;- Works in collaboration with research staff to facilitate an evaluation of the outreach program- Effectively communicates with geriatrician and other members of the patients care team- Provides case management support to clients to assist them in meeting their post-assessment care plans- Builds partnerships with community partners including developing and implementing referral pathways and providing education and support on implementing care recommendations for the clients to optimize their care- Provides outreach support to clients to help access resources and health care providers, including referrals made by geriatrician, and improve community connections/integration;- Works diligently to foster excellent relationships with internal and external partners;- Provides outreach services to clients who are unwilling or unable to attend office based appointments- Participates in client case management meetings when requested by either the client, outreach geriatrician or primary care team;- Records all client interactions in an objective and accurate manner that reflects organizational protocols and established regulatory practices;- Document all stages of the care transition and coordination process clearly, accurately and concisely- Acts as a liaison with the community partners to ensure appropriate client referrals;- Acts as an advocate on behalf of the registered client when deemed necessary;- Collaborate with in-patient units to facilitate coordinated transitions of client in the event of hospitalizations- Liaise with research personnel on evaluating the impact of this outreach initiative

**QUALIFICATIONS**:
- Must have a post-secondary qualification in: Social Service Work, Addictions and Mental Health, Community Service Work, Counseling, Geriatrics/gerontology or a related discipline- Should have a minimum 2 years¿ experience working with people experiencing homelessness- Must have strong organizational, coordination and administrative skills- Confidently use a scheduling software- Must have extensive knowledge of social service resources in the community- Must have demonstrated knowledge of the health care system- Must have a minimum of 2 years¿ experience working in an independent outreach position, meeting with clients alone in the community or in their homes- Must have experience in case management- Must have experience in engaging and advocating with older adults facing significant barriers to accessing health, social services and housing- Must be highly skilled in crisis management and intervention with clients- A commitment to a cooperative approach to problem solving- Ability to work independently and as part of a multidisciplinary team- Ability to respectfully and meaningfully engage clients experiencing homelessness; demonstrated understanding of the unique issues and barriers facing this population- Must have a demonstrated awareness of HIV/AIDS, HCV, harm reduction and related issues and their impact on clients (especially older adults) experiencing homelessness- Knowledge of addictions treatment modalities an asset- Experience working in a interprofessional team- Excellent written and verbal communications skills- Experience working with diverse communities with complex psycho-social needs including concurrent disorder- Demonstrated understanding of the impact of the social determinants of health and a commitment to working collaboratively with patients to mitigate these