Outreach Coordinator

The ED Outreach Coordinator - THRIVE 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 violence. As the core part of the THRIVE Hospital-based Violence Intervention Program, they meet patients at the time of violent injury to support their transition from hospital to community.

DUTIES & RESPONSIBILITIES:

- Coordinates the activities of outreach workers and ensures that the team collaborates closely both internally with Emergency Department (ED), Social Worker’s (SW), RNs as well as other staff in the hospital
- Facilitates weekly meetings attended by ED outreach workers to provide training opportunities, case discussions and support to each other
- Attends care plan meetings with the SW’s and ED staff for individuals who have been identified by staff as requiring a care plan
- Establishes and maintains therapeutic rapport with individuals to facilitate ability to successfully complete treatment plans
- Effectively assists individuals using evidence/strength based strategies to support complex medical and social needs
- Provides case management support to individuals to assist them in meeting their post-discharge care plans and provide support in times of crisis
- Provides outreach support to individuals to help access resources, connect with agencies and health care providers and improve community connections/integration
- Works collaboratively with the ED team and community partners to ensure post-discharge plans meet individual needs
- Engages in periodic evaluation and review of treatment goals and re-negotiates goals as is appropriate
- Participates in case management meetings when requested by either the individual or primary care team
- Provides outreach services to individuals who are unwilling or unable to attend office based appointment
- Records all 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
- Coordinates daily activities of Outreach Team
- Coordinates and collaborates with community colleagues to ensure program is operating in a collaborative way on program-wide basis
- Works diligently to foster excellent relationships with internal and external partners
- Ongoing communication with primary care providers, shelter workers, and long-term case management agencies for discharge planning and post-discharge care
- Closely collaborates with Care and Transition Facilitators, Social Workers, in hospital services (eg. ED, Rotary, Psychiatry and Addictions teams)
- Maintains connections and supports individuals in attending outpatient medical appointments
- Supports direct and successful connections to primary care

QUALIFICATIONS:

- Undergraduate degree required (specializing in Social Sciences would be an asset)
- A minimum 2 years’ experience working with individuals experiencing violence and/or repeat injury
- Lived experience with social disadvantage
- Extensive knowledge of social service resources in the community
- Experience working in an independent outreach position, meeting with individuals 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 individuals
- An ability to respectfully and meaningfully engage individuals experiencing violence and/or repeat injury;
- Demonstrated understanding of the unique issues and barriers facing this population
- A commitment to walk beside and support an individual as they build personal agency and independence
- A commitment to a cooperative approach to problem solving
- An ability to work independently and as part of a multidisciplinary team
- Knowledge of addictions treatment modalities an asset
- Experience working in an inter-professional team
- Excellent written and verbal communications skills
- Experience working with diverse communities with complex psycho-social needs

An understanding of the impact of the social determinants of health and a commitment to working collaboratively with patients to mitigate these