Comprehensive Care Specialist

Program Overview – Mental Health & Addictions, Community Care

This position is accountable to the Supervisor, Comprehensive Care and Integration Specialist Team at WoodGreen Community Services and offers social work/case management support to clients who are part of the MGH2Home program, which is a partnership between WoodGreen, Michael Garron Hospital, Spectrum and VHA Home Healthcare. This is a unique position supporting East Toronto Health Partners’ (ETHP) strategy to improve client transitions. This short-term transitional program (up to 90 days) involves supporting earlier discharges of adults with higher needs to reintegrate into their home and community. This multi-disciplinary team works as “one team” along with the client and designated family to address their complex health and social needs.

What You Will Do

  • Perform psychosocial assessments.
  • Develop goals with clients/patients/family members and implement service plans to address their priority and emerging needs.
  • Provide service/care co-ordination, navigation, short-term and mid-term planning and follow-up support within a maximum of a 90-day service period.
  • Work closely with the supervisor and team members to ensure supports are coordinated.
  • Provide clinical and/or supportive counseling 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.
  • Provide crisis intervention and practical assistance to clients and/or family or caregivers as required in homes and community settings.
  • Participate in case conferences and clinical meetings in order to ensure the coordination of services and a continuum of care for a smooth transition from hospital to community.
  • Provide advocacy support and advocate with clients and/or their family or caregivers.
  • Maintain flow through of clients in MGH2Home and prepare clients for discharge/transition
  • Provide service that is responsive, culturally and linguistically sensitive to the individual and caregivers needs, ensuring diversity, inclusion, belonging and equity values are achieved.
  • Keep current about the range of services available in other agencies.

What You Bring to the Team

  • Master of Social Work (M.S.W.) or post-graduate degree in relevant field.
  • Registration and in good standing with the College of Social Workers and Social Service Workers or another relevant regulatory body (i.e., CPRO)
  • 3+ years of related experience in mental health, addictions, geriatrics and/or social work.
  • Demonstrated experience working with older adults and seniors with mental health (including dementia) and/or substance use issues, chronic health issues, cognitive impairment, and responsive behaviours is required

What Will Set You Apart

  • Ability to support complex adults and senior populations including individuals who have considerate health challenges
  • Demonstrated ability in system navigation, service planning, implementation, and coordination, therapeutic or supportive counselling.
  • Demonstrated ability in working effectively in a multi-disciplinary team
  • Proven working knowledge of theories of addiction and evidence-based treatment models
  • Knowledge of and experience with a brief therapy modality, such as Narrative, Solution-Focused, Cognitive-Behavioural Therapy, Motivational Interviewing and Trauma-Informed approaches,
  • Comprehensive understanding of mental health, addictions, health and community sectors.
  • Strong assessment, clinical and intervention skills.
  • Effective oral, written communication skills and documentation skills.
  • Effective interpersonal, time management and organizational skills.
  • Proven ability to apply and practice anti-oppression, anti-racism, trauma-informed and harm Reduction principles, and strategies.
  • Ability to be self-directed, independent, flexible and exercise good judgment.
  • Ability to work from a client-centered approach.
  • Applied computer skills (MS word, excel, Internet) and ability to use client information systems.
  • Ability to communicate in a second language (Greek, Spanish, Bengali, Urdu, Tamil, Persian, Tagalog, Arabic, Mandarin, or Cantonese) is a strong asset.
  • Capable of fulfilling the physical and psychological demands of the job.  Accommodation for disabilities provided upon request.