Comprehensive Care Specialist (2026-320-CC)

Employment Type: Permanent Full-Time,Bargaining Unit (1 Vacancy)

Work Hours: 37.5 hours/week (Monday
- Friday 9am - 5pm)

Work Setting: Hybrid

Salary: $75,913.43

Final date to receive applications: August 27, 2026 by 11:59 pm

Competition #
-CC Comprehensive Care Specialist
-CC)

Employment Type :
Permanent Full-Time,Bargaining Unit (1 Vacancy)

Work Hours:

37.5 hours/week (Monday
- Friday 9am - 5pm) Work Setting:
Hybrid Salary: $75,913.43 Final date to receive applications:
August 27, 2026 by 11:59 pm

Visit (Use the "Apply for this Job" box below). to learn more about who we are and to review our Equity Statement.

We are committed to building an inclusive and diverse workforce, representative of the communities we serve. We encourage, and are pleased to consider, applications from Indigenous peoples, racialized persons/persons of colour, women/women identifying, persons with disabilities, 2

SLGBTQIA+ persons, and others who contribute towards promoting innovative ideas and solutions.

The Comprehensive Care Specialist is responsible for working independently and with the Comprehensive Care and Integration Specialist (CCIS) team to facilitate smooth care transitions (i.e. from acute care to community), to provide service coordination, psycho-social assessment, intensive case management, therapeutic and/or supportive counselling, and making referrals to various resources to improve outcomes for older adults, seniors and/or their family/caregivers.

The role includes collaborating with health care providers, and other resources in the community to enable individuals who are vulnerable, at risk and marginalized to live safely and independently in the community and reduce unnecessary hospitalizations and emergency room use.

• 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.

• 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 Wood Green 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

• 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…