The Concurrent Disorders Assertive Community Treatment (ACT) program is a new innovative partnership initiative between Unity Health Toronto (St. Michael’s Site) and Toronto Public Health. The program relies on an inter-professional team to provide community-based assertive community treatment services (home visits, community visits) to individuals living with serious mental illness and substance use disorders in downtown Toronto.

In addition to having their own caseload, the practicing operations leader will be available to support the interprofessional team of mental health and substance use clinicians who are providing community outreach, client support, case management and comprehensive treatment and rehabilitation seven days per week. Services provided by the team are individualized for each client.

The Concurrent Disorders ACT team provides services to clients who are 18-65 years old who are residing in downtown Toronto who have serious mental health and substance use disorders that significantly impair their ability to function and live well within the community. Clients may require one-to-one support with medications, symptom monitoring and management, physical health needs, substance use issues, finances, housing or shelter, access to basic needs such as food or clothing, activities of daily living, educational issues, work or meaningful activity, legal issues, social activities, family issues and support networks. On-call support is available 7 days per week.

Duties & Responsibilities

PROMOTING EFFECTIVE TRANSITIONS IN CARE

• Conducts community outreach visits with clients as required to promote their ongoing engagement with community mental health and substance use services
• Assesses the evolving community care needs of clients who are hospitalized or incarcerated
• Develops client-centered discharge plans to promote effective transitions in care from hospital/jail to community

COLLABORATIVE CARE PLANNING

• Identifies clients with complex care needs who meet program criteria for collaborative care planning
• Chairs collaborative care planning meetings with clients, families and community agencies in attendance
• Develops up to 100 collaborative care plans for clients
• Participates in the program related working groups

COACHING & MENTORING

• Provides monthly 1:1 coaching and mentoring sessions for individual clinicians to promote ongoing practice development

• Chairs weekly interprofessional recovery care planning meetings to review client goals and progress towards same

• Facilitates a monthly journal club to promote knowledge translation and integration of best practices in community mental health care in clinical care

• Assists with orientating new staff to the team ensuring staff are familiar with program processes, policies and procedures

• Provides educational in-service sessions for staff on issues and trends in community mental health care and substance use disorders.

OPERATIONAL RESPONSIBILITIES

• Primary accountability as a case manager for a small group of complex clients on the team (4-5 clients)
• Assesses all new referrals received for suitability with program and alignment with eligibility criteria
• Requests additional collateral information from care providers as required to promote effective decision making around clinical dispositions
• Suggests alternative options for community care when program is not the right fit
• Assigns new clients to team members
• Advocates for discharge from the program to a more appropriate level of care as required
• Ensures Master List of client visit plans is up-to-date and accurate
• Completes workload assignments for interprofessional clinicians on a weekly basis
• Revises daily workload assignments for clinicians as required based on changing client and/or program priorities
• Chairs daily morning interprofessional team meeting and advocates for appropriate level of care to be provided for new referrals
• Works collaboratively with team members to problem solve and resolve issues related to shared workload (i.e. mismatch between work assignments and roles, workload imbalances)
• Updates communication board with client and community safety alerts
• Monitors check in/check out protocol adherence by clinicians and escalates concerns to Clinical Manager as required
• Works collaboratively with the Clinical Manager to develop and implement strategies to improve work flow processes to increase efficiencies in workload and service delivery
• Collects data, prepares and submits statistical reports to meet MOH requirements
• Participates in quality improvement projects being implemented on the team
• Participates in Operations meeting and Community Mental Health Team Leader meetings and monthly business meetings held by the Clinical Leader Manager
• Participates in Mental Health and Addictions Service and hospital-wide committees as required.

Qualifications

• Master’s Degree as a regulated health care professional (Nursing, Social Work, Occupational Therapy) is required
• Minimum 2 years full-time experience working in a clinical capacity in a community mental health model of care is required
• Demonstrated experience providing recovery-oriented mental health and substance use care to individuals living with mental illness and/or substance is required
• Previous experience coaching and mentoring students and/or staff preferred
• Excellent knowledge of the ACT model of care and MOH community mental health standards is required
• Excellent knowledge of the values, principles and practices of recovery-oriented care are required
• Very good knowledge of the social determinants of health as well as the challenges faced by disadvantaged populations is required
• Excellent communication and interpersonal skills are required
• Excellent oral presentation and writing skills are required
• Very good conflict resolution and mediation skills are required
• Sound time management and organizational skills are required
• Familiarity with quality improvement science is preferred
• Excellent punctuality and attendance record are required

Unity Health Toronto is committed to creating an accessible and inclusive organization. We strive to provide a recruitment process that is barrier-free and in compliance with the Accessibility for Ontarians with Disabilities Act (AODA) and the Ontario Human Rights Code. We understand that you may require an accommodation at any stage of the recruitment process. When you are contacted, please inform the Talent Acquisition Specialist and we will work with you to meet your accommodation needs. We want to emphasize that all accommodation requests are handled with the utmost confidentiality, respecting your privacy and dignity.