Coordinator Transitional Care

**About SickKids**:
Dedicated exclusively to children and their families, The Hospital for Sick Children (SickKids) is one of the largest and most respected paediatric healthcare centres in the world. As innovators in child health, we lead and partner to improve the health of children through the integration of healthcare, leading-edge research and education. Our reputation would not have been built - nor could it be maintained - without the skills, knowledge and experience of the extraordinary people who come to work here every day. SickKids is committed to ongoing learning and development, and features a caring and supportive work environment that combines exceptionally high standards of practice.

When you join SickKids, you become part of our community. We share a commitment and determination to fulfill our vision of _Healthier Children. A Better World_.

Don’t miss out on the opportunity to work alongside the world’s best in paediatric healthcare.

**Position Description**:
**Department of Psychiatry - Outpatient Psychiatry: Transitional Care Coordinator (MSW)**

As part of its commitment to improving quality of care, SickKids has embarked on an exciting integration of its services that focus on brain and mental health conditions. The Brain and Mental Health Program is inclusive of programs and services focused on neuroscience, mental health conditions, inter-professional practice and a commitment to system capacity building through innovative partnerships with hospital and community organizations.

In collaboration with clinical point of care teams, the **Transitional Care Coordinator** will use expert interprofessional knowledge of internal and external resources to lead the coordination of and provide developmentally informed transitional support and specialized mental health services for patients in Outpatient Psychiatry. You will work with paediatric patients and their families transition to community providers, and or mental health organizations. You will work in a dynamic innovative environment committed to the development of innovative models of care, use of advancing technology to enable the work, and a commitment to team based, collaborative approaches that advance our commitment to excellence in patient and family centered care.

Through psychosocial assessments you will identify child/youth and family strengths, problem-solving abilities, interactions, attitudes, feelings and cultural issues in relation to the child¿s health and mental health, as well as supports/resources available to the family. You will assist patients and their families navigate and connect to community and/or resources within their communities that will support their recovery or ongoing treatment.

You will develop and implement a plan of intervention that addresses coping, adaptation, adherence and quality of life. This will be achieved through a variety of modalities including individual counseling, family work, group work, additional evidence-informed interventions, inter-professional consultation, case management, and community outreach and advocacy. Collaboration/communication with the health care team is essential. You will integrate research into practice and create, utilize and/or disseminate new knowledge. You will work to liaise with SickKids colleagues and their networks as well as establish your own service provider networks to provide comprehensive transition care.

**Here¿s What You¿ll Get To Do**:

- Work in collaboration with the interdisciplinary team to formulate a transition/discharge plan for patients and families
- Conduct psycho/social and motivational assessments with patients and families experiencing acute or chronic complex mental health conditions.
- Provide developmentally informed transitional support from the SickKids to community adult agencies for seamless and effective discharge planning.
- Provide family education, counselling and support through brief interventions.
- Facilitate multiple care aspects (e.g. case coordination, information sharing, implementation of practical clinical strategies, system navigation).
- Coordinate and provide care that is safe, timely, effective, efficient, equitable, patient and family centered and meaningful to the adolescent
- Promote quality and cost-effective interventions and outcomes.
- Develop effective working relationships with relevant SickKids colleagues and cooperate with community service providers and agencies throughout the entire case management process.
- Collaborate/communicate with the inter-professional health care
- Assume responsibility for all aspects of practice including performance metrics reflecting productivity and utilization.
- Practice in a manner that is consistent with the philosophy of continuous quality improvement and evidence-based practice.

**Here¿s What You¿ll Need**:

- A Masters degree in Social Work or a regulated health profession
- Registration and good standing with the relevant college
- An understan