Hospital to Home Case Manager

**Who we are**:
Canadian Mental Health Association Durham is an integrated community mental health and primary care hub that has been providing mental health services to Durham Region for over 60 years.

During that time, it has evolved to provide a broad range of services to individuals and their families experiencing mental health challenges, from information and education to case management, psychosocial rehabilitation, housing and primary healthcare. These services are provided through inter-professional teams focused on providing clinically based services that, in addition to dealing with client mental health issues, address social determinants of health using the recovery model.

**Overview**:Provide case management services to all patients accessing emergency room, inpatient and outpatient services of Lakeridge Health Oshawa (Hospital to Home Program).

**Responsibilities**:

- Works collaboratively with Lakeridge Health Oshawa (LHO), Durham Mental Health Services and Pinewood staff to assist with discharge planning and distribution of client caseloads amongst agencies
- Coordinates all referrals from LHO to CMHA Durham programs and services
- Attends daily ER rounds and/or inpatient rounds with psychiatrist and community partners to determine referral distribution based on best fit
- Arranges crisis and withdrawal management beds as needed
- Obtains and reviews current patient list, electronic medical record/referral spreadsheet and inpatient form to provide information to emergency room psychiatrist
- Presents statistical data monthly to CMHA Durham Senior Management Team
- Attends meetings with Hospital to Home Group as required
- Prepares and maintains statistical monthly and yearly records associated with program functions as per agency guidelines
- Responsible for coordinating case conferences and care plans
- Provides case management services in an individualized, supportive, and flexible manner
- Provides intake and triage services on a rotational basis within Community Connection Services
- Provides support via phone and face to face engagement to retain client and caregivers in active care
- Screens potential clients for eligibility into relevant CMHA Durham mental health and addiction services
- Provides system navigation for clients, caregivers and families to help engage individuals into services and/or connecting them with alternate/complimentary supports within the community
- Completes intake assessments that identify the client’s needs and abilities through information obtained from the client and other sources
- Liaises and consults with referral sources concerning recommendations and requests for additional information
- Facilitates linkages to needed and wanted services, supports and resources, both internal and external to the organization
- Collaborates with external partners to facilitate access to and coordination of services to minimize gaps in service
- Adheres to agency policy and procedure when responding to high-risk/aggressive individuals entering CMHA Durham
- Documents client contacts as outlined in the CMHA Durham policies and procedures
- Performs other tasks as assigned by management

**Skills**:

- Post
- secondary education ( i.e. mental health, social sciences or human services) and a minimum of three years related experience or equivalent combination of education and experience
- Ability to effectively respond to clients, caregivers and families who are presenting in crisis or distress (crisis intervention/de-escalation skills)
- Ability to integrate CMHA Durham’s philosophy of being a “welcoming organization” into every day practice
- Ability to work collaboratively with a team to respond to clients, caregivers or families who may require immediate services/supports
- Sound knowledge the Mental Health Act, Health Care Consent Act, social service benefits and related legislation in Ontario
- Ability to develop and maintain a positive therapeutic relationship with clients
- Ability to develop and maintain positive relationships with community partners and represent the agency in a professional manner at all times
- Excellent communication (written and verbal) skills
- Ability to work with individuals of diverse backgrounds
- Ability to acquire and utilize community resources effectively to meet client needs
- Excellent problem solving skills to weigh all factors when assessing clients
- Ability to adapt to changing circumstances
- Ability to work a variable schedule which may include evenings and weekends as required
- Valid Ontario Driver’s license, access to a dependable vehicle in safe working order and appropriate insurance coverage
- Knowledge of MS Office (Word, Excel, PowerPoint, and Outlook), as well as the internet
- Fluency in oral and written French is an asset

**Working Conditions**:

- Works on site in office settings and off site in hospital and community environments (public and residential)
- May be exposed to abusive/irate clients, distractions,