Social Worker

**Social Worker (Community Transitional Worker)**

**SPRINT Senior Care** began caring for seniors and enabling seniors to care for themselves in 1983. We continue to do so today as an accredited, not-for-profit community support service agency in Toronto by offering a wide range of practical and low-cost services to seniors and their caregivers. Our services help seniors stay safe, connected, and live as independently as possible. They also prevent premature or inappropriate institutionalization.

**Location**: Sunnybrook Health Sciences Centre and SPRINT Senior Care locations.

**Job Summary**:

- The Community Transitional Worker engages clients and stakeholders to work on common goals to improve client independence, level of functioning and connections to their community. The Community Transitional Worker helps clients and their families navigate and support the plan needed for a smooth transition out of the hospital to home; and to ensure the client obtains needed services through a variety of interventions, such as advocacy and referrals to additional community organizations. They work with Sunnybrook’s Interprofessional Team, clients and caregivers to organize appropriate community services and engage in collaborative discharge planning and ongoing client goal setting.

**Responsibilities**:

- Work in close collaboration with a team of internal and external support to coordinate all aspects of client case management.
- Work closely in collaboration with Sunnybrook Hospital’s Interprofessional Team to plan and execute safe and sustainable discharges from hospital and avoid unnecessary hospital admissions to inpatient units
- Actively participate in and be an integral contributor to inter-disciplinary teams
- Screen and assess clients’ eligibility for SPRINT Senior Care services; provide consultation and counselling regarding the appropriateness of services.
- Provide post-discharge support to clients and caregivers and connect with current and new community services
- Provide crisis intervention as needed.
- Develop and maintain excellent collaborative relationships with referral sources and resources.
- Provide case management services
- Provide consultation and community resource navigation to hospital staff as needed
- Plan, co-ordinate and provide facilitative leadership to self-help, therapeutic, problem-solving, and educational group programs as part of SPRINT Senior Care services.
- Complete all client assessments and reassessments, including the interRAI CHA, and develop care plans.
- Consult with and train internal staff and volunteers.
- Provide ongoing monitoring and reassessment of clients’ social, mental and physical status and modify care plans to respond to changes.
- Participate in and provide leadership to partnerships between current SPRINT Senior Care partners and establish new partnerships to support community-organizing activities.
- Complete all required client care statistical tracking.
- Complete timely and professional documentation in all appropriate databases tracking client care.
- Facilitate community organizing with SPRINT Senior Care clients to support client identified/directed advocacy.
- Develop strategies to reach out to isolated older adults and implement strategies to facilitate their access to health and social services.
- Provide clinical supervision to placement students from colleges and universities.

**Qualifications**:

- BSW or MSW, registration with the OCSWSSW required.
- Experience in community capacity building, health promotion, adult education, or social group work.
- Excellent communication, negotiation, and mediation skills.
- Knowledge of the health care system and community resources.
- Demonstrated knowledge of and experience with managing/coordinating “complex care” transitions into the community is an asset.
- Superior ability to manage multiple tasks and set priorities in a fast-paced environment.
- Demonstrated commitment to People Centered Care approach and principles.
- Demonstrate an intermediate level for database concepts and structures.
- Ability to work both independently and collaboratively within a team.
- Excellent verbal and written communication skills.

**Our Caring Workplace**:
Working at SPRINT Senior Care, you'll have the opportunity to be a part of a passionate team committed to providing client-centred, high-quality services to seniors in our service area.
SPRINT Senior Care’s inclusive environment is one of many benefits for staff, including SPRINT Senior Care’s dedication to staff wellness, a comprehensive benefits package for eligible employees, and comprehensive training and tuition reimbursement programs.

**How to Apply**: