Intensive Geriatric Service Worker 4L Medicine

St. Joseph's Health Centre, Toronto; Toronto; Presencial; CAD 39.000 - 50.000; Jornada completa

Descripción de la vacante

Unity Health Toronto seeks an Intensive Geriatric Service Worker to support care for older adults with physical, mental and social frailty. You will work with the Specialized Geriatric Services, Geriatric Social Work Navigator, and ED Case Manager to implement care plans and coordinate services across health and social care networks.

You will help transition older adults to community-based supports, build partnerships with agencies, and ensure access to resources needed for living safely in the

Formación

• Graduate qualifications in counselling, social service work or related field and relevant professional background.
• Experience with older adults and medical complexity is essential.
• Ability to collaborate with multiple community resources and agencies.
• Familiarity with geriatric care principles and emergency department flow.
• Knowledge of recovery models in geriatric mental health and substance use.
• Proficient with MS Office (Word, Excel, Outlook) and basic apps.

Responsabilidades

• Engage with individuals unable to access needed resources and assist with immediate needs.
• Facilitate involvement of social networks in implementing care plans.
• Provide intensive support post-transition from ED or acute care to community care.
• Coordinate and integrate client information across the care continuum.
• Conduct home visits to implement and update care plans.
• Liaise with community agencies to ensure appropriate referrals.
• Serve as a resource for staff and providers on community resources and strategies.
• Maintain relationships with key community partners and primary care programs.

Conocimientos

Healthcare experience

Case management

Community resources

Geriatrics knowledge

Social determinants

Recovery model

MS Office

Interdisciplinary teamwork

Communication skills

Educación

Counselling / Social Service Work / Addictions and Mental Health / Community Service Work / Registered Practical Nurse / gerontology or related discipline

Undergraduate degree in aging or gerontology

Herramientas

Microsoft Office

Descripción del empleo

Description

The IGSW will work with various programs as part of an inter-\u2011professional team supporting the care of patients who are affected by physical, mental and social frailty. This role will implement care plans developed in collaboration with older adults and their families by the Specialized Geriatric Services, Geriatric Social Work Navigator, and Geriatric Emergency Nurse in partnership with the Community Care Access Emergency Department Case Manager. The IGSW will assist with the development of an integrated delivery of service through partnerships with agencies providing services for older adults across the health and social care system; provide transition services for older adults with complex specialized geriatric concerns; and ensure that these individuals are able to obtain the services/resources deemed necessary in the identified care plan to live successfully in the community.

Intensive Geriatric Service Worker

Description

The IGSW will work with various programs as part of an inter-\u2011professional team supporting the care of patients who are affected by physical, mental and social frailty. This role will implement care plans developed in collaboration with older adults and their families by the Specialized Geriatric Services, Geriatric Social Work Navigator, and Geriatric Emergency Nurse in partnership with the Community Care Access Emergency Department Case Manager. The IGSW will assist with the development of an integrated delivery of service through partnerships with agencies providing services for older adults across the health and social care system; provide transition services for older adults with complex specialized geriatric concerns; and ensure that these individuals are able to obtain the services/resources deemed necessary in the identified care plan to live successfully in the community.

Duties And Responsibilities

• Engage people who are unable to access needed resources or services; assist people in addressing immediate needs (e.g. food, medical attention, medications, transportation, and other community-based services)
• Facilitate with the person’s/family’s agreement, the involvement of members of the social network in the successful implementation of the older adult’s individual care plan
• Provides intensive support following the transition from Emergency Department, acute care or ambulatory specialized services; provide direct support to the older adult in accessing, receiving services and/or attending appointments and/or day program
• Assist with coordination and integration of client information across the continuum
• Provide home visits, building on existing documentation, assessments and service plans implement care plan
• Act as a liaison with the community agencies to ensure appropriate client referrals.
• Act as a resource and provide information, guidance, support and consultation to other staff and community care providers in terms of strategies and community resources for their clients.
• Maintain community relationships with key community partners, i.e. Home and Community Care Support Services, mental health, substance use agencies, and social service agencies, primary care service program members.
• Serve as a primary contact for the older adult/family and coordinate services received across the system. If multiple agencies are involved, designate (in collaboration with person/family and other service providers) lead agency for service coordination.
• Collaborate with Specialized Geriatric Services team members and clinicians who made referrals to:
• Ensure that the service plan is implemented as agreed upon.
• Ensure that multi-disciplinary assessments are coordinated and integrated into a single service plan.
• Involve the older adult/family and social network in the monitoring, evaluating, and revising of service goals.
• Facilitate and/or provide agreed upon service to individual, and their family/support network in a variety of contexts (home, office, other community location) depending upon need and the person’s/family’s unique circumstances.
• Involve relevant community services, resources, and network members in the provision of treatment and support to the fullest extent possible.
• Develop intervention and support plans that reduce reliance on the formal emergency department and acute care settings

Qualifications

• Graduate of Counselling, Social Service Work, Addictions and Mental Health, Community Service Work, Registered Practical Nurse, gerontology or a related discipline from an accredited post-secondary institution;
• An undergraduate degree in aging or gerontology (considered an asset/preferred)
• A minimum 2 years experience working with older people with medical complexity and experiencing frailty
• Recent experience working in a community role as a case manager or case worker preferred; ability to work collaboratively with formal and informal community resources
• Knowledge base of community-based service principles and modalities and Emergency Department and Alternate Level of Care (ALC) opportunities
• Sound knowledge of inner city populations and community issues and geriatrics/gerontology
• Excellent understanding of the impact of the social determinants of health and a commitment to working collaboratively with patients to mitigate these
• Demonstrates excellent knowledge of recovery model as it applies to frail older adults, mental health and substance use issues
• Demonstrates excellent knowledge, understanding, and skills when using Microsoft office and its related programs including Word, excel, outlook and apps on PC, smart tablet and phone.

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.