Outreach Worker Emergency Department

The Emergency Department (ED) Outreach Worker works as a part of an inter-professional team in Emergency Medicine (EM) at St. Michael’s Hospital supporting the care of patients who are affected by social disadvantaged.

They are responsible for time-limited case management, outreach support, and community liaison for patients who are identified as socially disadvantaged (e.g. experiencing homelessness, income and/or food insecurity or in need of MH and addictions care). The position will connect with patients at the start of the ED and in some cases prior when notified by community agencies or healthcare providers and assist in navigation during their ED and hospital stay. They will help to reconnect the patient with their existing case managers and identify with the patient opportunities for enhanced or new connections that may address the needs identified. When there is an existing case manager, they will involve that person early in the patient’s visit. Along with being a part of their ED and hospital care, they will be part of their community care. They will support patients in the post-discharge days, weeks and months to assist them to successfully (re-) connect with existing community and primary care supports. When these supports do not exist, they will work with the individual to develop new connections to these services. Their role will be important in improving the physical, social and emotional health of the disadvantaged individuals that visit the St. Michael’s Hospital Emergency Department.

**DUTIES & RESPONSIBILITIES**
- Establishes and maintains therapeutic rapport with clients to facilitate a positive navigation in the ED and in the days, weeks and months following their visit
- Ensures a smooth, warm/positive transition between providers
- Effectively assists clients using trauma-informed care and evidence/strength-based strategies
- Provides case management support to clients to assist them in meeting their post-discharge 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 community agencies to re-connect clients with existing supports
- Works collaboratively with social workers and community agencies to ensure post-discharge plans meet client needs
- 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 client goals and re-calibrates goals as is appropriate
- Participates in client case management meetings when requested by either the client or healthcare team
- Records all client interactions in an objective and accurate manner that reflects organizational protocols and established regulatory practices
- Documents 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. Drug and Alcohol agencies, Probation, Pharmacies, Mental Health and others
- Strengthens internal partnerships with the GIM, SMH mental health and addictions program
- Collaborates with in-patient units and other outreach workers to facilitate coordinated transitions of client discharges back to the community
- Spearheads educational opportunities that increase the knowledge capacity of the Department staff to manage the needs of patients with addictions
- Works in collaboration with EM and research staff to facilitate an evaluation of outreach care as an intervention for people experiencing homelessness or other social disadvantage

**QUALIFICATIONS**:

- College diploma required
- A minimum 2 years’ experience working with people experiencing homelessness
- Lived experience with social disadvantage
- Extensive knowledge of social service resources in the community
- Experience working in an independent outreach position, meeting with clients alone in the community or in their homes
- Experience in case management, and goal-setting
- Experience in engaging people facing significant barriers to accessing health, social services and housing
- Strong organizational, coordination and administrative skills
- Skill in crisis management and intervention with clients
- An ability to respectfully and meaningfully engage clients experiencing homelessness; demonstrated understanding of the unique issues and barriers facing this population
- A commitment to walk beside and support a client as the