Intensive Case Manager

**Introduction**:
The role of the ICM would include psychosocial, emotional, and cultural support as well as health care planning, health, and social service navigation, wholistic support including connection to Traditional and cultural programs and services, advocacy and capacity building, health care planning, administrative navigation, and outreach. While aspects of this role are similar to DAHC’s current Aboriginal Patient Navigators, the key difference is that the ICM’s would be working with a smaller, more targeted caseload of complex individuals identified by primary care. They would have the capacity to provide longer term supports at a higher frequency.

The ICM would receive triaged referrals from primary care meeting the following criteria: Indigenous community members of all ages, accessing primary care services at DAHC who are of the highest complexity including those,
- Seeing multiple specialists, with multiple diagnoses and comorbidities
- Frequent hospital admissions and/or emergency department visits
- Requiring extensive psychosocial and social services, in particular those experiencing homelessness or housing issues
- Needing a difficult or complex referral
- Who are homebound and require frequent home visits
- Having family communication issues and/or no support system
- Experiencing mental health and addictions issues, or needing pain management coordination
- Using internal resources frequently i.e. high staff demands, frequent phone calls or visits, required supports extend beyond primary care scope leaving a gap in service

**Roles & Responsibilities**:

- Assess patient needs and work with them to optimize their health and wellness
- Supporting patients to understand, choose and use different types of health programs and services
- Provide emotional support and encouragement related to treatment decisions
- Offer interim counselling support to bridge wait times for service
- Managing patient care received by multiple providers and bridging communication between patient, family, and providers
- Attending appointments with clients, offering home visits, and accompanying primary care home visits
- Providing education, psychosocial support and assistance to patients accessing and using a range of services
- Reminding patients of their appointments for primary care, specialists, and explaining what they are for as clients often forget or get confused when there are multiple appointments
- Follow up on referrals, screening and adherence to follow-up care and health care provider recommendations
- Coordinate social services and complex referrals to facilitate information exchange
- Support complex discharge planning
- Support access to transportation, ID services, food, housing, financial assistance (insurance claims, ODSP, OW, WSIB etc), Jordan’s Principle, 60s Scoop Settlements, Self-determination claims etc.
- Understanding and using health coverage - obtaining financial resources, health benefits, drug benefits, dental care, mental health counselling, social supports
- Identify adult day programs, assisted living, long term care homes, caregiver supports etc.
- Referrals to programs and services, including referral follow up
- Support for family and caregivers
- Follow up with specialists to obtain test results and reports
- Follow through of care beyond the administration of a referral done by primary care
- Connect our patients to community resources and build community capacity with other organizations.
- Support patients in overcoming fears and coping with new diagnoses
- Make necessary links between physical, social, emotional, and spiritual well-being

**Required Knowledge, Skills, Qualifiers**:

- Completion of a post-secondary degree or diploma in a social work or health care related field.
- Demonstrated understanding of the health care and social services system
- 2-5+ years’ experience working in an Indigenous health or social service organization, hospital or community-based case management, health promotion, or public health.
- Ability to interact with diverse and cultural clients, showing compassion, sensitivity, and support with knowledge of Harm Reduction principles and practices, including a familiarity with Indigenous ways of being.
- Must have a valid driver’s license and reliable transportation.
- Sound computer and documentation (manual/computer based) skills with Electronic Medical Record systems and Intermediate knowledge of Microsoft Office capabilities.
- Advanced Microsoft Office skills.
- Excellent organizational skills.
- Strong written and verbal communication skills.

**Job Types**: Full-time, Permanent

Pay: $64,167.00 per year

**Benefits**:

- Company pension
- Dental care
- Disability insurance
- Employee assistance program
- Extended health care
- Flexible schedule
- Life insurance
- On-site parking
- Paid time off
- Vision care

Schedule:

- Monday to Friday

Ability to commute/relocate:

- Brantford, ON N3T 3C5: reliably commute or plan t