Clinical Social Worker, Comprehensive Care & Integration Specialist

Overview – Comprehensive Care & Integration Specialist Team, Community Care

The Comprehensive Care & Integration (CCI) Specialist team supports transitions from hospital to community for individuals living with complex mental health, addictions, and health needs and psychogeriatric concerns.  This team provides short term case management; attachment to primary care; and promotes coordinated care planning within an anti-oppressive, trauma-informed, harm reduction, and mental health recovery framework.

What You Will Do

Referrals and Outreach:

  • Develop trust and rapport with clients and hospital staff in order to identify individuals who could benefit from social work support and transitional care coordination.
  • Follow up with referral source(s) to learn more about the client, reason for hospitalization and/or reason for referral, to support in development of Coordinated Care Plan (CCP).
  • Develop relationships with other service providers in order to make seamless, effective referrals and service connections.
  • Work closely with central intake and program managers to identify clients with frequent hospital/ED use who may benefit from CCIS support to reduce unnecessary hospital use.

Direct Client Support:

  • Perform psychosocial and/or psychological and geriatric assessments.
  • Provide short-term case management services (up to 90 days) to clients through the development and implementation of a care plan and/or Coordinated Care Plan (CCP) to address their priority and emerging needs.
  • Provide short-term intensive care coordination and work closely with the CCIS team, hospitals, and other referral sources to support clients and facilitate smooth transitions between hospital and community.
  • Provide clinical and/or supportive counselling to clients utilizing a wide range of therapeutic approaches that best meet the clients’ needs and circumstances.
  • Provide preliminary assessment of risk in crisis situations, consult and devise an intervention and action plan, and provide crisis intervention.
  • Link clients and facilitate access to internal and external resources, programs, and services.
  • Work to prevent future avoidable ED visits, 30-day hospital re-admission, and Alternative Level of Care (ALC) placements for clients referred to the CCIS team.
  • Facilitate or lead social and/or support groups as required.

Comprehensive Care and Integration Specialist Team Member:

  • Provide suggestions, support, and resources to other CCI specialists and participate actively as part of the CCIS team, sharing expertise.
  • Participate in Team Calls and manage all referrals accepted, including data collection/tracking.


  • Provide mentorship, training, and/or supervision to student placements and volunteers.
  • Maintain records and documentation and collect statistical data.

What You Bring to the Team

  • Masters of Social Work (MSW) required.
  • Registered Social Worker (RSW) in good standing with the Ontario College of Social Workers and Social Service Workers.
  • Three (3) years of related experience in mental health, addictions, and/or social work.
  • Experience facilitating psycho-social groups and supporting individuals with significant mental health and/or addictions issues, cognitive impairment (e.g. dementia), and chronic health issues from a harm reduction, trauma informed, and mental health recovery approach.
  • Experience in conflict mediation, client engagement, and community development.

What Will Set You Apart

  • Demonstrated ability in supporting individuals who have complex mental health and/or addiction issues, geriatric issues, cognitive impairment, history of trauma, violence/abuse, chronic physical health issues, etc.
  • Proven working knowledge of theories of addiction, evidence-based treatment models, and best practice approaches.
  • Demonstrated experience and ability in providing therapeutic and supportive counselling.
  • Knowledge and experience providing addictions counselling and support.
  • Proven ability in providing intensive and short-term case management, care coordination, and system navigation.
  • Strong assessment, de-escalation, and crisis intervention skills
  • Strong interpersonal and conflict resolution skills.
  • Excellent organizational and time management skills.
  • Excellent oral and written communication and documentation skills.
  • Self-directed and independent with proven experience working effectively as a team member in collaboration with other community professionals.
  • Ability to exercise good judgment and flexibility.
  • Ability to work from a client-centred approach.
  • Comprehensive understanding and knowledge of the mental health, addictions, geriatrics, health sector, and community resources.
  • Demonstrate knowledge of issues affecting marginalized communities, policies, legislation, programs, and other issues related to scope of practice and social determinant of health.
  • Applied computer skills (MS word, Excel, Internet) and ability to use client information systems.
  • Training and experience using InterRAI CHA, Pirouette, and ConnectingOntario is an asset.
  • Proficiency in second language, written and oral, is a strong asset.