Pathways to Care Outreach Coordinator

***:Journey Home Hospice supports patients who have experienced homelessness and/or vulnerable housing with a patient-centered approach to care. Our interdisciplinary team works together to create exceptional experiences grounded in a holistic model of care. We are currently seeking a talented Pathways to Care Outreach Coordinator to take the lead role in creating referral and intake pathways and awareness for patients in the Greater Toronto Area who may be eligible to receive care at the hospice. If you have a strong clinical background - preference for individuals with a nursing, social work, or social services background - and a passion for building systems, engaging others, and contributing to health equity in our region, we would be delighted to hear from you.

The Pathways to Care Outreach Coordinator will be responsible for eight key outcomes:

- facilitating access, referrals to, and awareness about the hospice and referring patients to agencies that can provide additional services they may require;
- explaining social determinants of health and how Journey Home Hospice is addressing those;
- building relationships with potential patients to facilitate more comfortable admissions when necessary, including supporting patients with advance care planning, in collaboration with other organizations as necessary, to enhance a seamless transition into hospice care (i.e OPGT referral, Completion of DNR, establishing connection with SDM;
- creating a network of collaborators who can help to profile the hospice and direct potential patients to our care;
- taking primary responsibility for monitoring and reporting on program outcomes and evaluations to internal and external sources
- organizing outreach programs for community members who may experience homelessness or need help and helping community members get access to hospice services;
- offering educational opportunities and organizing awareness campaigns for issues pertaining to end of life, mental health, homelessness, and substance use;
- conducting assessment/intake interviews with clients in a variety of locations: public (e.g., on the sidewalk, in public squares, parks and ravines, etc.), homeless and low-income service settings (e.g., hostels, drop-in centres, etc.) and institutional settings (e.g., hospitals, court houses, etc) and assess client's functional, income, employment and housing status to determine program eligibility.

These goals will be achieved through a variety of outreach activities, including but not limited to regular in-person and virtual workshops, relationship building with priority community organizations and potential referral sites, engagement with potential patient populations to answer questions about the hospice and help to clarify admissions processes, engaging key collaborators to amplify the work, and taking primary responsibility for all quality control metrics and reporting to program funders. Taking direction from the Journey Home Hospice Director of Care and working cooperatively with the interdisciplinary team and Saint Elizabeth Foundation staff, the Coordinator will also be available to support communications and fundraising activities for the program as required.

**POSITION RESPONSIBILITIES**:
**Outreach, Awareness Building, and Patient Intake**
- Build outreach networks with individuals and organizations engaged in health equity work who may also be serving people experiencing homelessness or other structural vulnerabilities
- Host in-person and virtual workshops to explain the Journey Home Hospice program, our goals, and the referral process for patients
- Distribute materials in person and electronically to raise awareness about the hospice, our admissions process, and build referral pathways for potential patients
- Make personal visits to existing and potential collaborators to build strong relationships and ongoing awareness with the individual(s) who may work with our potential population and provide referrals to the hospice.
- Research, plan, and create direct outreach opportunities to individuals who may be experiencing homelessness, vulnerable housing, and other structural vulnerabilities to education them about Journey Home Hospice, begin building relationships, and explaining how to self-refer or make a referral on behalf of a loved one to the hospice program.
- In cooperation with the Director of Care and other clinical team members at the hospice, work with potential patients to address their outstanding needs prior to admission, including but not limited to offering tours of the hospice, enrolling individuals into wellness and day programming, or creating out-patient care plans to support their end-of-life journey while living in the community.
- Engage with and/or mentor student interns who may assist with program goals during placements at the hospice.
- Conduct Needs Assessments by Identifying and understand client's wants and requirements. Assess patients’ current situation and determine