Care Coordinator

**Organization Overview**:
Stepping Stone is a community-based agency that believes in the Housing First philosophies and practices. We strive to improve the quality of life for people who are struggling with chronic homelessness, significant mental health issues and substance misuse. We offer this by providing shelter support and supportive, affordable housing to our participants with individualized, participant-driven support plans. The Stepping Stone team collaborates with community services within Guelph-Wellington to help support these plans and to offer our participants wrap-around supports as needed.

**Job Summary**:
Reporting to the Clinical Manager, the Care Coordinator is responsible for leading care plans with individuals that are part of all Stepping Stone Programs. This role will ensure that individual’s health and housing care plans are being supported by an interorganizational team to move towards health and housing stability. This role will work within a person centered approach delivering the support from a complex capable, harm reduction and trauma informed framework.

**Qualifications, Skills and Experience**:

- Bachelors of Social Work Degree or related undergraduate degree
- Thorough knowledge of assessing risk and confident in creating plans to address risk
- At least three (3) years of experience in a community mental health setting working with adults recovering from serious mental illness.
- Mental health and addictions knowledge along with brain injury training and expertise.
- Thorough knowledge and understanding of community resources
- Thorough knowledge of administering clinical assessments
- Flexible, adaptive and creative problem solver
- Enjoys being part of building something new, and has energy to provide leadership
- Committed to working within a complex capable, harm-reduction philosophy and trauma informed foundation of care
- Practices from an anti-oppressive and racially informed framework
- Ability to multitask and work both independently and within in a team environment
- Effective written and oral communication skills
- Excellent time management, decision making and organizational skills
- Three (3) to five (5) years’ experience working with individuals who have experienced homelessness, use substances, and/or experience mental health struggles

**Overview of Duties and Responsibilities**:

- Oversee care planning to ensure mental health, addiction and medical goals are being created and carried forward with a team comprising of both internal staff and external partners
- Create care plans through an ABI, trauma-informed and person-centred lens
- Assist the Emergency Shelter and 24/7 Shelter programs by providing support plans and transitions plans from shelter programs to ensure continuity of care.
- Development of care plans in collaboration with Life Skills workers according to the needs of the client
- Support staff in the ongoing management of care plans
- Support in ensuring continuity of care in the community (when an individual is housed or transferred to another shelter)
- Create transition and discharge plans that are shared across the team for clear communication.
- Lead crisis planning to ensure safety of the entire team, clients and the community.
- Advocate and liaison with healthcare professionals, community partners and supports to ensure coordinated care.
- Mental health and addictions knowledge along with brain injury training and expertise.
- Complete Risk Assessments
- Develop stage-matched, client centered care
- Maintain client records in a timely and accurate manner
- Attend both internal staff meetings and client care meetings as required
- Follow PHIPA standards

**Funding Requirements**:
Reporting quarterly on the following outcomes:

- Number of times a client received support with the justice system including probation meetings, court appearances, support to adhere with Wellness Court orders, ensuring adherence to Community Treatment Orders.
- Number of times a client received assistance accessing mental health and/or addiction challenges including referrals to formal supports such as CMHA, attending appointments, connection to addictions supports.
- Number of times a client received assistance accessing primary care needs including referrals, attending appointments, medication strategies, appointment reminder strategies, follow up medical appts.

**Working Environment / Schedule**:

- 35 hour regular work week (70 hours / pay period)
- Afternoon schedule to ensure presence at the Overnight Emergency Shelter.
- The Coordinator will work thirty-five (35) hours per week, 2pm-10pm with the hours being flexible to the needs of clients.
- Flexibility to work weekends and evenings when required (availability to participate in the weekend on-call rotation)
- Work with clients and staff directly on the shelter and PSH site
- Exposed to stress due to dealing with clients in difficult personal circumstances

**Compensation and Benefits**:

- Hou