Homeless Outreach Counsellor, Rotary Transition Centre

The Homeless Outreach Counsellor works as a part of an inter-professional team in the Emergency Department (ED) supporting the post-hospital visit care plans of patients who are experiencing homelessness. The ED serves as a point of entry for patients who arrive by ambulance, and as a hub for specialized medical care. The ED provides immediate medical attention for severe illnesses and injuries 24/7.

Reporting to the Manager, Homeless and Outreach Services, the Homeless Outreach Counsellor is responsible for time-limited case management, outreach support, and community liaison for people experiencing homelessness. The position will connect with people who are visiting the Emergency Department, and will support clients for 90 days after their hospital visit to assist them in following their care plan and connect to long-term social and health supports, aiming to reduce their need for Emergency Department presentation.

**Responsibilities**:
- Establishes and maintains therapeutic rapport with clients to facilitate commitment to adhering to treatment plans;- Effectively assists clients through their ambivalence and resistance to change using evidence/strength based strategies;- Supports clients experiencing homelessness during their Emergency Department visit and completes intake for longer term case management and outreach- Provides case management support to clients to assist them in meeting their post-visit care plans and provide support in times of crisis;- Provides outreach support to clients to help access resources, connect with agencies and health care providers and improve community connections/integration;- Works collaboratively with ED staff and physicians to ensure care plans meet client needs and facilitate coordinated transitions of care and client discharges back to the community.- 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;- Engages in periodic evaluation and review of care goals and re-negotiates goals as is appropriate;- Participates in client case management meetings when requested by either the client 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.- Builds partnerships with community agencies including developing and implementing referral pathways;- Acts as a liaison with the community agencies to ensure appropriate client referrals;- Acts as an advocate on behalf of the registered client when deemed necessary;- Engages in day-to-day liaison activities with relevant professionals and community members;- Promotes and maintains community relationship with key stake holders; i.e. substance use and harm reduction focused organizations, primary care providers, Probation, Pharmacies, Mental Health and others;- Strengthen internal partnerships with the SMH outreach services;- Collaborate with in-patient units and outreach services if client is admitted to facilitate coordinated transitions of care and client discharges back to the community.- Participates in ongoing meetings with ED team and Outreach Services staff for case reviews and reporting- Spearhead educational opportunities that increase the knowledge capacity of the Emergency Department staff to manage the needs of patients experiencing homelessness;- Works in collaboration with research staff to facilitate an evaluation of providing post-visit care planning and outreach support as an intervention for people experiencing homelessness.

**Qualifications**:
- Must have a post-secondary qualification in: Social Service Work, Addictions and Mental Health, Community Service Work, Counselling or a related discipline;- Must have a minimum 3 years' experience working with people experiencing homelessness- Must have extensive knowledge of social service resources in the community.- Must have experience working in an independent outreach position, meeting with clients alone in the community or in their homes or shelters;- Must have experience in case management, and goal-setting;- Must have experience in engaging people facing significant barriers to accessing health, social services and housing;- Strong organizational, coordination and administrative skills;- 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;- Awareness of HIV/AIDS, HCV, harm reduction and related issues and their impact on clients experiencing homelessness- Knowledge of addictions treatment modalities