The Role

Uses a biopsychosocial lens to provide client support and consults with staff and service providers regarding client issues. Facilitates the delivery of Supported Living, Integrated Assisted Living Program (IALP), and Homemaking Services, including assessment processes, principles of services, policy and procedures, and evaluation measures. 

Determines financial and functional eligibility for homemaking services through assessing applicants' financial and health-related information, strengths and deficits in instrumental activities of daily living, and current informal and formal supports.

Duties/Responsibilities

• Provides consultation/supportive counselling to clients, care partners, and members of health care teams to mitigate risk and resolve service issues. 
• Provides pre-and-post admission support (e.g., tours, education) to prospective supported living tenants and their care partners. Determines eligibility and suitability of individuals referred to the program.  Supports a smooth transition into supported living in collaboration with staff, internal regional partners, and external partners. 
• Responds to information requests about homemaking services. Reviews and screens referrals and assesses clients for priority status. Monitors, maintains, and updates waitlist.
• Provides oversight, guidance, and support to contracted agencies to ensure client needs are met.
• Completes required annual assessments and coordinates services for clients, using a self-directed care model by recommending and implementing life skill strategies. 
• Conducts community home visits to assess clients’ financial and functional eligibility, homemaking needs, and suitability/safety of home environments. Determines eligibility based on legislation, standards, regulations, and policies. Refers ineligible clients to other community resources.
• Develops, implements, monitors, and reassesses individualized service plans in collaboration with clients, care partners, contracted service providers, and other health care and support services.  
• Promotes resources to clients per policies, and initiates referrals to community support services as needed. Acts as liaison/advocate for clients with external partners as appropriate. Also coordinates conferences for additional support with community services and resources, in consultation with the team.
• Maintains program data and documentation standards consistent with professional guidelines, policies, and legislation.
• Facilitates education and interest group sessions that focus on developing and maintaining life skills, emotional health and wellbeing, and physical health.
• Intervenes and assists during periods of client crisis, as appropriate, and facilitates supports.
• Ensures proper documentation, storage, and collection of health information, per legislation and policy.
• Educates tenants, care partners, service providers, and the community regarding supported living and organizational services.  
• Provides discharge planning assistance to supportive housing tenants. Collaborates with community agencies to facilitate transfers to other community services or housing options. 
• Ensures service delivery and operations meet regulatory compliance requirements and person-centered service philosophy.
• Collaborates with mental health providers to support clients around mental health and wellbeing. 
• Identifies and addresses unsafe conditions and practices, including reporting and removing hazards.
• Allocates program resources and monitors program budget. 
• Participates in program development, evaluation, quality improvement activities, and professional development.  
• Is available for staff to consult in the supervisor’s absence, and supports members of the team as needed. 
• Represents the program on community committees and networks.  
• Performs related duties as required.

Knowledge, Skills, and Abilities

• Knowledge and skills are normally acquired through a post-secondary degree or diploma in a social services or health-related discipline, plus related experience in a community-based mental health or older adult environment.
• Knowledge of health and community resources and service delivery, assessment and referral supportive counselling, and crisis intervention. 
• Knowledge and skill to work with older adults and their care partners regarding complex health, mental health, and addictions. Understanding of social determinants of health, community program delivery, assessment, supportive counselling, and community resources. 
• Knowledge of and ability to comply with policies, procedures, and legislation (e.g. Assisted Living Policy, 2023, Homemaking and Nursing Services Act and Regulations, 1990)
• Assessment, analytical, interviewing, organizational, and continuous improvement skills to perform functional, environmental, and risk assessments; coordinate and monitor service delivery; recommend program improvements; and assess and address the needs of supportive housing tenants.
• Communication, human relations, leadership, and facilitation skills to provide supportive counselling; establish and maintain supportive relationships with tenants and their care partners; interview and advise clients and their care partners (including negotiating service plans); resolve conflicts, mediate disputes, and respond to complaints and inquiries; communicate effectively with the care team, agencies, and the public; and participate as an effective team member. 
• Ability to write clear, concise reports, minutes, correspondence to care partners and agencies, policies, procedures, and client progress documents. 
• Ability to read and understand policies, procedures, journals, newsletters, correspondence, charts, reports, and client files. 
• Computer skills with ability to use software such as Microsoft Office, databases, and a clinical documentation system.  
• Must have a tuberculosis (TB) test and required immunization(s).  
• Must provide an acceptable vulnerable sector police check.
• Ability to travel within and outside Waterloo Region. 
• Ability to implement and monitor compliance with the departmental vision and philosophy for integrated customer service delivery within the division, across divisions, across departments, and within the broader community.
• Ability to work flexible hours and variable shifts, including evenings, holidays and weekends, as required.
• Ability to support and demonstrate the Region’s values.