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SalaryPOSITION SUMMARY:
Under the direction of the Director, Quality & Performance, this position is responsible for helping to create effective links between appropriate health and social resources to minimize emergency room visits and hospital admissions, addressing social isolation and working with at risk individuals in the community.
This position will adopt a holistic approach in helping clients to engage pro-actively with the community, to address social determinants of health and wellness.
This position collaborates with various stakeholders, including hospital staff, primary care providers, and other community organizations, to employ a multidisciplinary approach in assisting clients with their transition between different environments. The aim is to support clients in accessing additional programs and services offered within the community.
ROLES AND RESPONSIBILITIES
Client Service:
1. Participates in the circle of care and conducts client needs assessments to identify risk factors and support client needs.
2. Links clients with community resources that have been identified during transition and as part of annual service planning.
3. Assesses risk factors and develops client Safety Plans to address the challenges that contribute to overuse of the healthcare system.
4. Develops communication plans and promotes use of community services as outlined in the client service plan.
5. Travels to other locations within the Halton region to connect with partners, programs and clients as required
6. Connects with appropriate transportation systems to plan the anticipated and ongoing transportation needs of clients.
7. Facilitates communication between clients and their families and members of the health care team.
8. Completes referral processes with clients for appropriate and applicable community support services in line with their goals of care.
9. Facilitates client meetings with community providers and advocates on behalf of clients.
10. Uses internal and external resources and other relevant discipline supports as required in order to assist with successful transitions to home and supports to live well in the community.
11. Communicates regularly with clients, care partners, hospital staff and family members as appropriate.
12. Connects with clients at home and in the community, and attends appointments with clients as required, to ensure successful transitions to home and supports to living well in the community.
13. Participates in discharge planning and provides support to clients to ensure successful integration into the community.
14. Collects information, records and maintains client files, updates client information and logs each interaction into client files.
15. Maintains client summary documentation including demographics for each client.
16. Performs activities of daily living tasks as required.
17. Follows all safety protocols when working within the community.
Community Collaboration and Engagement:
1. Collaborates with program team and Leader, hospitals, community partners and working groups to develop plans for gathering data/measurement indicators.
2. In collaboration with hospitals and partner organizations tracks scorecard/measurement indicators and experience surveys to assess client satisfaction from time of referral to return to community.
3. Collaborates with hospital and primary care teams to establish referral process.
4. Participates in designing, delivering and evaluating the overall program to meet the needs of clients.
5. Attends allied health team meetings to facilitate referral process and provides information regarding community services as needed.
6. Participates in training to ensure the effective use of client information systems that support client referral and community access to services and activities.
7. Works with internal and partner organizations to engage isolated clients, including seniors, in regular physical and social activities as appropriate.
8. Participates in community planning internally, with partner organizations and hospital staff in order to provide information on client services as required.
9. Participates in community engagement and advocacy to ensure inclusion and maximize independence of clients.
Other:
1. Participates in regular supervision sessions with direct supervisor.
2. Attends and actively participates in team meetings and training as required.
3. Works in close collaboration with the staff of the Ontario Health Team and community partners.
4. Complies with the service and agency policies and procedures as outlined in the Policies and Procedures Manuals.
5. Complies with the duties imposed by law or contract and the policies and procedures for performing the job in a safe and healthy manner.
6. Takes an active role in promoting and protecting personal health and safety and the health and safety of others, both staff and consumers (Sec.28(1)OHSA)
7. Performs other duties as assigned.
The above tasks are representative but not all-inclusive.
Qualifications:
o University Degree in Health or Social Sciences field, or College Diploma with three (3) years’ work experience in the Health and/or Social Sciences field. Professional designation is an asset.
o Experience working with seniors, and extensive knowledge of the local health care system and community resources.
o Excellent interpersonal, oral and written communication skills.
o Proven ability to work as a team member and demonstrated ability to make sound judgement decision independently.
o Experience with quality improvement initiatives related to care delivery processes.
o Demonstrated initiative and experience working independently with minimal supervision.
o Proficiency with Microsoft Office programs, internet research, and ability to learn and master other computer programs as needed (i.e CareDove, Clinical Connect).
o Access to a vehicle is required, as travel between sites may be required. Employees who travel for work related purposes must have reliable transportation, a valid Ontario driver’s license and a minimum of $1,000,000 liability insurance coverage.
Links2Care reaffirms its policy and maintains a work environment free from discrimination, treating all employees with dignity and respect. All employees share in the responsibility and commitment to equal employment opportunity. Links2Care does not discriminate against any employee or applicant based on age, ancestry, color, family or medical care leave, gender identity or expression, genetic information, marital status, medical condition, national origin, physical or mental disability, political affiliation, protected veteran status, race, religion, sex (including pregnancy), sexual orientation, or any other characteristic protected by applicable federal and provincial laws, regulations, and ordinances. We adhere to these principles in all aspects of employment, including recruitment, hiring, training, compensation, promotion, benefits, social and recreational programs, and discipline.
It is the policy of Links2Care to provide reasonable accommodation to qualified employees who have protected disabilities to the extent required by applicable laws, regulations, and ordinances where a particular employee works. Links2Care is committed to providing accessible employment practices that comply with the Accessibility for Ontarians with Disabilities Act (‘AODA’). Should any applicant require accommodation through the application, interview, or selection processes, please contact our Human Resources Department at 905-844-0252 ext. 130.
Job Type: Full-time
Salary: $45,000.00-$50,000.00 per year
Benefits:
- Company events
- Dental care
- Employee assistance program
- Flexible schedule
- On-site parking
- Vision care
Flexible Language Requirement:
- French not required
Schedule:
- Day shift
- Monday to Friday
Ability to Commute:
- Georgetown, ON L7G 4B5 (required)
Work Location: In person
