Community Worker

As part of a collaborative team, receive referrals, respond to initial inquires for programs and services, and provide client-focused support and rapid response intervention for an assigned portfolio, such as: problem identification, referral and services coordination, individual/group support/advocacy, caregiver/public education, agency consultation, home visits, and service advocacy. Assess client needs and develop goal-oriented service plan to address assessment outcomes. Independently or in partnership with other agency providers, coordinate service plan to reduce risk factors to optimize client ability to remain independent within the community. Apply a professional approach demonstrating respectful, non-judgemental, and solution-focused work. Maintain documentation and integrated electronic client files. Perform public relations and formal presentation activities to promote Seniors Community Programs across the Niagara Region.

• College Diploma in Social Services/Gerontology, or an equivalent combination of education, training and experience

• Post Diploma Certificate in Geriatric Mental Health or Dementia or equivalent

• University Degree in related discipline (Gerontology, Psychology, Sociology or Health Sciences) considered an asset

• Over three years of experience in the field of community outreach services (preferred) or applied behavioural sciences, with emphasis on working with senior citizens and specifically service coordination for individuals with disabling conditions (mental health, dementia, chronic disease management)

• Demonstrated work experience in a multi-agency, integrated work environment

• Knowledge of community support services for seniors

• Knowledge of family dynamics techniques for working with a diverse groups of individuals

• Knowledge of client/participant safety issues and demonstrated capacity to apply client/participant safety practices

• Demonstrated work experience in the use of electronic client record management systems for data requirements and related client service planning and outcomes documentation

• Excellent communication, analytical, problem solving, and time management skills

• Excellent demonstrated team building skills in support of common outcome measures

• Excellent documentation skills and attention to detail

• Proficiency in a second language will be considered an asset

• Intermediate skills with database applications (i.e. MS Access), web-based applications, and Microsoft Office Suite

• Knowledge/experience in administering and completing assessments using “standardized assessment tools” (such as interRAI CHA, PIECES, MoCA, Safe Talk).

• Demonstrated ability to build awareness of service supports available to seniors

• Demonstrated ability to work collaboratively to achieve program requirements and outcomes

• In accordance with the Corporate Criminal Record Check Policy, the position requires the incumbent to undergo a Criminal Records Check including Vulnerable Sector Query and submit a Canadian Police Clearance Certificate

• Able to travel to various locations across the Niagara Region and may be based in remote offices including: Niagara Regional Housing sites, alternate Niagara Region office sites and other locations as required for portfolio assignments

• Receive and respond to inquiries from internal, external, and general public stakeholders regarding seniors in need of support and coordinate the service needs of an assigned case load; inclusive of: allegations of elder abuse, vulnerable, at-risk, and isolated seniors who may present with underlying dementia, mental health, and/or physical deficits. All work is conducted within departmental policies and best practice guidelines.

• Conduct Home visits independently, jointly, and/or in collaboration with other agencies/professionals to inform the assessment process related to environmental and health influences.

• Complete assessments using a variety of standardized tools (interRAI CHA, PIECES, MoCA, SAFE TALK) to examine both psychosocial and functional ability. Assessment results are discussed with the client, imminent risk situations prioritized (evictions, abuse, addictions, risk environment) and with consent a goal-oriented plan of service is developed and implemented.

• Consult with client and /or care partner to develop an individualized service plan outlining goals, intervention strategies, responsibilities, time-lines, desired outcomes, and links to agency providers.

• Objectively monitor each individual service plan with an outcome orientation, achieved through a professional approach, demonstrating a positive, courteous, non-judgmental, respectful and empathetic manner and adhering to the client rights and responsibilities to self-determination.

• Serving as an Integrated Community Lead (ICL), staff will work in partnership with client and/or family, other service providers; as consent dictates, to develop an integrated community service plan for complex issues, identifying goals, responsibilities, timelines, and desired outcomes. The plan is monitored for effectiveness and client satisfaction and adjustments made as required. Upon desired goal attainment, the ICL may be passed to an on-going service provider.

• Facilitate, liaise, consult, and/or participate in meetings (team meetings, collaborative partner meetings, care teleconferences or direct interaction with key individuals/agencies) in addressing ‘hard to serve’ client needs. Seeks to de-escalate potential crisis and maintain positive working relationship with appropriate staff/agency for risk mitigation, and or issue resolution. Escalates situations to the Manager, Outreach Services as per established practice.

• Establish and maintain positive working relationships internal (i.e. NRH, Public Health) and external (i.e. Home and Community Care, Hospitals, physicians, suppliers of service, health agencies) to the organization. Ensures communication remains neutral, focussed on priority needs for a solution orientated outcome achieved through consensus.

• Advocate for client needs, negotiating with community and care partners for services to support the identified assessed needs. Provides insight, objective information of current state, to inform and guide staff (internal and external) decisions of service provision.

• Communicate in an effective manner adjusting style to functioning level of the client and/or other participants to optimize understanding and clarity of message. Obtain client consent as per established practice to facilitate personal information sharing with other agencies to support service outcomes.

• Responsible for accurate record keeping in accordance with established practice that includes: electronic data entry related to: client documentation - concise, factual case-notes of all contact with client, family and related agency staff pertaining to the assessment and service plan; and data entry informing statistical data output (i.e. telephone contact, face to face visit).

• Responsible for public education related to Seniors community programs, internal/external to the organization, providing information sessions to target audiences and tailoring the content to the intended audience which will include: Plan, implement and participate in information events ensuring advanced operational details are in place for successful implementation.

• Participate in the planning and evaluating of assigned programs, as directed by the Manager, Outreach Services, for the purpose of informing process development, tools and resource support documentation (i.e. best practice guidelines, standard operating procedures) and/or new program proposal development.

• Maintain knowledge of services, programs, legislation (i.e. OAS, ODSP, Capacity Assessment) and related issues impacting on clients and the senior population. Assist clients in the completion of required applications for services (i.e. transportation, housing, financial).

• Participate /attend and/or complete required training and professional development sessions based on staff needs, program requirements; as approved by Outreach Services Program Manager.

• Provide support to families and assist in acquiring the necessary resources to support care giving responsibilities, problem solve, and advocate for the client ensuring accurate understanding of rights and obligations.

• In consultation with the Outreach Services Program Manager provide input into volunteer roles and assignments to support the program need and/or student placements/volunteer experiences; providing direct guidance to assigned students and necessary input the Manager to support accurate evaluation.

• Actively participate as a collaborative partner with other agencies connected to Seniors Services in the Niagara region to ensure comprehensive delivery of services, improved access to services as health prevention strategies evidenced through direct referrals, advocacy efforts, and/or mobilizing resources in support of independent living.

• Carry out all duties with appropriate attention for staff/ client/participant safety and in accordance with Niagara Region, policies and procedures.