Home First Enhanced Care Coordinator

Position Overview:

Reporting to the CEO; the Enhanced Care Coordinator (ECC) works as a member of a multidisciplinary professional team at Scarborough Health Network. The Coordinator contributes to team decisions for individualized discharge planning in assessment, implementation and evaluation of appropriate community support services to enable the safe and effective discharge of medically stable hospitalized patients. Creative problem-solving is required to identify and eliminate or manage barriers to safe and timely discharge from hospital. Candidate must be comfortable working on their own, as they will be working off site.

The Enhanced Care Coordinator develops and supports systems and processes to ensure coordination with TransCare® Community Support Services (CSS) being designated as Lead Agency for Scarborough CSS. The ECC maintains good working relationships with our Scarborough CSS partnering organizations and provides support and guidance to staff to ensure the program mandate is met; and participates as an effective member with Home and Community Care, hospital teams as well as patients and their families.

The Enhanced Care Coordinator works closely with the Supported Referral initiative, the Home at Last (HAL) Program, Home to Stay and In-Home Services to seamlessly coordinate and schedule patient care needs.

The Enhanced Care Coordinator also provides case management for transition of services from Home First to private pay and makes necessary linkages and referrals to other organizations.

Please note:

This is a contract from September 8, 2025 to May 8, 2027, with a possibility of extension; The worksite is Birchmount Hospital.

Primary Duties & Responsibilities:

· Conduct patient visits and attend team rounds for identification and follow up for patients to assess for eligibility;

· Participate in discharge planning meetings to coordinate community support services and contribute to decision making by the team;

· Manages services within TransCare Community Support Services’ policies, procedures and staff limitations;

· Planning, implementing and evaluating service(s) in consultation with the multidisciplinary professional team along with onsite hospital interdisciplinary teams;

· Liaising with hospitals and community organizations as required for service provision, monitoring and follow up;

· Completing verbal and written reports and presentations; maintaining statistical data and records;

· Establishing effective working relationships and maintaining appropriate community, organization and hospital contacts

· Communicating effectively in various forums

· Developing and/or assisting with program/TransCare initiatives

· Provide counseling, advocacy and support to clients with one-on-one case management;

· Crisis-intervention – follow-up on issues around neglect, abuse, mental health and emergencies;

· Perform other duties and responsibilities as directed by CEO.

Job Specifications:

· Degree in Social Work or Diploma in Social Service Work or related health service field;

· Minimum of two years’ experience in service coordination or case management functions;

· Knowledge of the principles and practices of community support services; knowledge of healthcare and community support resources in Scarborough Region

· Strong familiarity with community support services;

· Sensitive to the cultural needs of clients from various ethnic groups;

· Excellent interpersonal, communication and multi-tasking skills;

· Maintain strict confidentiality and abide by Data Sharing Agreements for restricted access into partner portals and electronic referrals

· Self-directed and disciplined to manage multiple caseloads and meet deadlines;

· Must be able to work in a fast-paced team environment;

· A strong understanding of holistic care, systems development and inter-organizational / inter-professional cooperation.

· Results oriented, takes initiative and capable of working independently;

· Must have basic computer skills (knowledge of Microsoft Outlook, word and excel);

· Possession of a valid Ontario driver’s license and access to a vehicle;

· Excellent oral and written communication skills;

· Second language preferable;

· Previous experience in a Community Support Agency;

· Knowledge of AlayaCare database would be beneficial

· Familiarity with InterRAI CHA.

Work Condition and Physical Capabilities:

· Monday to Friday from 8:30 to 4:30 with occasional evenings or weekends as required, primarily at hospital site and occasionally at Head Office when required;

· General office environment;

· Visits to client homes and exposure to various living environments, such as hoarding or infestation;

· Significant amount of computer and telephone use;

· Can lift &/ or carry 6-13.5kg (15-30 lbs).

Job Application Instructions:

Please submit your job applications via email to [email protected], quoting the position to which you are applying to in the subject line, no later than August 29, 2025. All applications will be held in strict confidence.

TransCare® is dedicated to addressing specific clients’ needs including; gender, language and cultural requirements in particular, when providing personal care for older adults with challenges. Selection of personnel will be based on current clients’ needs at the time of posting.

We thank you for your interest in applying to TransCare®; however only successful candidates selected for an interview will be contacted.

Disclaimer:

TransCare® Community Support Services is an inclusive and equal opportunity employer. We welcome applications from diverse individuals who self-identify on the basis of any of the protected grounds under the Human Rights Code. We are committed to integration and maintaining the independence of individuals and removing barriers to accessibility in the workplace. We are committed to full compliance with the Human Rights Code, the Accessibility for Ontarians with Disabilities Act, The Pay Equity Act, the Occupational Health and Safety Act, and all other applicable legislation.

The information in this description has been designed to indicate the general nature and level of work performed by employees in this classification. It is not designed to contain or be interpreted as a comprehensive inventory of all duties, responsibilities, and qualifications required by employees assigned to this job. The agency reserves the right to make changes to this position as business dictates.

Job Types: Full-time, Contract
Contract length: 18 months

Pay: $29.73-$32.37 per hour

Education:

• DCS / DEC (preferred)

Experience:

• in service coordination or case management: 2 years (required)

Licence/Certification:

• Ontario driver’s license (required)

Work Location: In person