Homeless Outreach Counsellor

The Homeless Outreach Counsellor works as a part of an inter-professional team in General Internal Medicine (GIM) supporting the post-discharge care plans of patients who are experiencing homelessness. The GIM Unit specializes in the diagnosis and treatment of a broad range of diseases involving all organ systems, and are especially skilled in the management of patients with complex medical needs.

The Homeless Outreach Counsellor is responsible for time-limited case management, outreach support, and community liaison for patients experiencing homelessness. The position will connect with patients while admitted to the General Internal Medicine Unit, and will support patients for 90 days post-discharge to assist them in following their care plan and connect to long-term supports, thereby preventing hospital readmission.

**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;
- 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 discharge planners 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 treatment 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. Drug and Alcohol agencies, Probation, Pharmacies, Mental Health and others;
- Strengthen internal partnerships with the SMH mental health and addictions program;
- Collaborate with in-patient units to facilitate coordinated transitions of client discharges back to the community.
- Spearhead educational opportunities that increase the knowledge capacity of the Department staff to manage the needs of patients with addictions;
- Works in collaboration with GIM and research staff to facilitate an evaluation of providing post-discharge care planning 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 2 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;
- 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 an asset;
- Experience working in a interprofessional team;
- Excellent written and verbal communications skills;
- Experience working with diverse communities with complex psycho-social needs including concurrent disorders;
- An understanding of the impact of the social determinants of health and a commitment to working collaboratively with patients to mitigate these;