Comprehensive Care Specialist (2026-196-CC)

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. Work with hospital staff to identify and engage clients and support hospital staff in making referrals to the CCIS team, as appropriate. When necessary, follow up with referral source(s) to learn more about the client being referred, 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 CCU 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 service/care co-ordination, system navigation, short-term and long-term planning and follow-up support. 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 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. Link clients with internal resources, program and services within Community Care Unit and WoodGreen as well as with external resources and programs. 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 access to service including arranging for phone/in-person interpretation when needed. In consultation with internal and external partners, develop appropriate onsite programming and supports. Facilitate or lead social and/or support groups as required. 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 Discuss options for expanding referral sources while balancing CCIS capacity, operational issues and offer recommendation to continue to develop

Hub model

General: Ensure the organization’s policies and procedures are carried out. Ensure excellent communication with other staff who work on-site at the various specified locations, including PSWs, housing workers, Supervisors and other partners in the community. Keep current about the range of services available in other agencies. Provide mentorship, training and/or supervision to student placements and volunteers. Participate in team and unit meetings regularly, and promote the healthy functioning of the team and unit. Participate in ongoing training and education. Participate in supervision sessions and annual performance appraisals with program manager. Maintain appropriate records and documentation in a timely manner and collect statistical data required for the accountability of the program. Represent the unit on internal and/or external staff committees as directed by program manager. Perform other duties as assigned. What You Bring to the Team Masters of Social Work or post-graduate degree in relevant field MSW or Post-Graduate degree in a related area with 2+ years of extensive crisis/complex seniors experience or BSW with 5+ years of extensive crisis/complex/seniors’ experience Registration in good standing with the Ontario College of Social workers and Social Service Workers or another relevant regulatory body in Ontario (e.g. CPRO or COTO). Minimum of 3 years related experience in mental health, addictions, and/or social work. Demonstrated 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 is required. What Will Set You Apart Experience in conflict mediation, client engagement and community development is required. 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. Knowledge of, experience with, and demonstrated ability in providing therapeutic and supportive counseling. Knowledge and experience providing addictions counseling and support. Proven ability in providing intensive and short-term case management, care coordination and system navigation. Strong assessment skills. Strong de-escalation and crisis intervention skills Strong interpersonal and conflict resolution skills to work collaboratively with all service providers and stakeholders. Excellent organizational and time management skills. Excellent oral and written communication skills and documentation skills. Self-directed and independent, but also proven experience in 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 suite, Pirouette and ConnectingOntario is an asset. Proficiency in second language, written and oral, is a strong asset. Due to WoodGreen’s multi-site locations we reserve the right to relocate the incumbent to another site, in the same position performing the same duties, as may be dictated by program needs. Reasonable notice of such site relocation will be given. Capable of fulfilling the physical and psychological demands of the job as per the attached Position Demands Analysis. Accommodations for disabilities provided upon request. WoodGreen is an equal opportunity employer. We are committed to providing an inclusive and barrier-free selection process and work environment. If contacted in relation to an employment opportunity, please advise our People & Culture representatives at careers@woodgreen.org of the accommodation measures required. Information received relating to accommodation will be addressed confidentially. This public job posting uses AI-powered tools to screen, assess, or select applicants.