Job Details

Description DUTIES & RESPONSIBILITIES Functions In The Capacity Of Care Coordinator

• Utilizes components of evidence-based models of care coordination and case management to foster continuity of treatment.
• Co-ordinates a patient’s specific needs with appropriate community supports or social services.
• Follows up with direct contacts and advocates on a patient’s behalf for support services/resources.
• Reviews and enters referrals in consultation with the interprofessional team.
• Facilitates timely access to services through established partnerships and supports.
• Supports effective discharge coordination through psychosocial assessment in collaboration with the interprofessional team.
• Provides recovery-based treatment, rehabilitation and follow-up services to patients.
• Co-ordinates the treatment plan with a patient, natural supports, social services, and community service providers.
• Assists patients with personal/environmental causes of social dysfunction which predispose illness or interfere with achievement of patient goals.
• Consults and collaborates with the interprofessional team.
• Ensures health records are current, accurate, contain relevant information about patients and are managed in a manner that protects patient privacy and are in line with OCSWSSW standards.

Professional Practice

• Offers educational consultation in regard to community resources for patients’ psychosocial adjustment to mental illnesses, and reintegration into the community.
• Engages in professional practice activities.
• Performs committee work as part of the ongoing work of the Ontario Shores Social Work Professional Advisory Council.
• Attends professional and clinical events and continuous development of social work competence.
• Provides consulting services to other social workers or members of the interprofessional team in relation to social work activities.
• Assists in providing professional supervision to BSW social work students as required.

Community Liaison And Resources Person

• Represents Ontario Shores by serving on administrative, clinical and community boards, committees and in other cooperative forums.
• Identifies community program needs.
• Provides information/education to community agencies/groups.

Program Staff

• Participates collaboratively in hospital and program committees/meetings in planning, implementing and evaluating of hospital/program policies and procedures.
• Participates in program education, research projects.
• Engages in ongoing education.
• Patient safety and organizational safety (environmental and employee) standards are embedded into the job descriptions of everyone employed by the hospital.
• Responsible to recognize and report patient, staff, and environment safety issues, identify and implement preventative and corrective actions, within the scope of this role.
• Performs all work at all times in compliance with all hospital policies and procedures and legislation (Occupational Health &Safety Act, Fire Code, WHMIS, etc.) relevant to health and safety, security (including relational/therapeutic security) and potential risk hazards, and in particular, “duties of the worker” as defined in Section 28 of the OH&S Act.
• Assist in continuous quality improvement and evaluation of the interprofessional clinical team services/partnerships by:
• Assisting in the collection, analysis and preparation of pertinent data for periodic and regular reports and where permitted formulating, collecting and analyzing clinical research data;
• Recommending changes to meet determined needs;
• Attending to management information system requirements;

Staffing & Licensing Requirements

• Bachelor’s of Social Work degree from a recognized university.
• Current registration as a Social Worker with the Ontario College of Social Workers and Social Service Workers.
• Valid Ontario Driver’s License.

KNOWLEDGE

• Knowledge of mental health and social work theory and practice gained through preparation from an undergraduate social work program – i.e. recovery-based psychosocial rehabilitation principles and techniques, including: group, family/individual, crisis intervention; counseling on goals setting and adjustments to change - appropriate to working with people who have a mental illness and their natural supports.
• Knowledge of theories involving social interactions and dynamics of individuals and families and conditions which contribute to dysfunction in order to facilitate development of appropriate treatment plans.
• Sound knowledge and skill of evidence based social work assessment, identification, treatment, interventions and best practices which incorporates psychosocial rehabilitation values and principles and applied in mental health settings i.e. hospital and community;
• Advanced knowledge of relevant community resources and service systems to facilitate support for people with mental illness and natural supports through the process of community development, integration and advocacy;
• Knowledge of facility/program policies and procedures by which: to advocate on patient’s behalf to safeguard patient entitlements and rights, and to ensure accepted social work standards of practice; to apply coordinated and consistent procedures in emergency or crisis intervention/management situations; and to report appropriate observations to supervisor that may affect patient treatment, care, or safety.
• Knowledge of relevant legislation - e.g. Mental Health Act, Long Term Care Act, Health Care Consent Act, Homes for Special Care Act, Regulated Health Professions Act, Social Work Act … etc - to ensure compliance and consistency, and to ensure that legislated client entitlements such as consent to treatment are observed.

Skills

• Reasoning skills to gather and interpret information from multiple informants and sources - e.g. patients, families, community health services providers … etc., and e.g. referral documents, court and other historical reports, clinical notes … etc. - to identify problems, evaluate information and draw conclusions when developing a treatment plan.
• Analytical skills to apply a bio-psycho-social model and an ecological perspective to evaluate service needs and requirement for differential intervention in service delivery. Also, to elicit and interpret information from patients, families, community health service providers and other sources; to identify problems, evaluate information and draw conclusions when developing a treatment plan;
• Exercising independent judgment and initiative particularly as they relate to treatment of people with serious mental illness and working with their caregivers in the community.
• Sensitivity in responding to ethno-cultural and religious aspects of patient circumstances in rendering assessment, treatment planning, and advocacy intervention.
• Collaborative skills in working with an interprofessional team, and fostering cooperation with multiple stakeholders when recommending and implementing treatment plans.
• Good oral and written communication skills; good interpersonal skills both in teamwork and patient-interaction, especially that involved in working with people with a mental illness; tact in clarifying information about psychosocial illness and treatment to client and significant others; sensitivity in negotiation and advocacy functions; good problem-solving skills.
• Verbal and written communication skills in order to work effectively within the interprofessional team, to clarify information about treatment and discharge plans with patients and natural supports; provide education and consultation regarding mental health treatment issues to community based service providers.
• Organizational skills to facilitate community services and resource acquisition in order to maintain community tenure and to function independently while working within the interprofessional team utilizing components of care coordination.
• Computer skills at functional level to develop documents, produce research data, ability to use e-mail, intra and internet;
• Position may require travel.

FREEDOM OF ACTION

• Working independently and collaboratively within the interprofessional team context and within facility, hospital, legislative and social work practice parameters.
• Communicating issues such as non-compliance with social work standards and facility procedures to the team for group discussion and resolution, and to supervisor.
• Developing community liaison programs which are responsive to hospital and community requirements, and treatment programs to meet patient/family/stakeholder needs and goals.
• Freedom of action and initiative in assessing patients’ needs, in collaboration with the interprofessional team, determining which hospital/community resources would best fulfill these needs, and in facilitating linkages with those resources.
• Making recommendations to supervisor on new programs or major program changes.
• Participating in research and analysis of data as well as quality improvement tasks.

This is part of the OPSEU bargaining unit - Link to OPSEU Wage Table

Job Posting Closing October 15th 2025. Please note any job applications after the closing date will not be considered. This is a 6 month Contract 1 Vacancy Available Qualifications 0" style="display: none;">

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