Case Manager in Kingston, Ontario at Addiction and Mental Health Services - KFLA

The Case Manager works as a member of an interprofessional team and is responsible for providing case management services to individuals with a serious mental illness who are living in the community. This position works in close partnership with acute care hospitals and community service agencies to provide assessment, intervention, supportive counseling, service coordination and follow-up to adults, 16 years of age and older. All services are provided in accordance with the mission, vision, values and established protocols of the Agency.

There are a number of specialty Case Management roles supporting clients across multiple programs at the Agency, further information on variations of the role can be found at the end of this job description.

1. Direct Service Provision:
   1. Assessment & Planning:
      1. Provides ongoing support services to individuals that are flexible and driven by individual choice, reducing the need for hospitalization.
      2. Conducts a comprehensive individualized assessment to address immediate and ongoing individual needs in a timely manner.
      3. Collaborates with the individual in the development of an individualized treatment plan
      4. Ensures that the individualized treatment plan incorporates the individual’s goals, values, resources and service requirements, emphasizing current strengths and abilities and increasing competencies
      5. Ensures assessment of strengths and abilities are conducted in relation to the individual’s environment
      6. Strives to include members of the individual’s social network in the assessment and planning process with the individual’s consent.
      7. Assists individual’s compliance with Community Treatment Orders (CTO), coordinating services and assisting individuals to fulfill their responsibilities as outlined in their CTO
      8. Provides services in the environment of choice of the individual wherever possible, ensuring the safety and security of the consumer and the case manager
      9. Projects a brief in the potential for change and growth
      10. Supports the opportunity for individuals to take responsibility for self-determination
      11. Utilizes community resources, adhering to established Agency protocols.

1. Intervention:
   1. Provides interventions such as engagement, crisis planning and prevention conflict resolution, support and linkage to appropriate levels of service, advocating for services that are accessible, relevant and coordinated.
   2. Develops a trusting relationship with individuals through regular and predictable contact offering supportive counseling (excluding psychotherapy and/or psychoanalysis) empathetic listening and paraphrasing, problem solving, guidance and facilitative discussions as appropriate.
   3. Provides flexible programs and services to individuals while continually monitoring, modifying and adapting, based on client’s recovery, with a focus on personal empowerment
   4. Assists directly with activities of daily living which address the individuals need for food, housing and healthcare, etc.
      1. Advocates for the rights of individuals with community agencies, service providers and landlords assisting individual with system navigation and resource acquisition as appropriate.
         1. Assists individual to avoid crisis and to develop intervention and coping strategies to address symptom management and side effects of psychotropic medication.
            1. Provides transportation to clients, as appropriate, in order to facilitate community outings and attend appointments as required.
               1. Educates individual on recovery and relapse prevention
                  1. Develops a crisis plan in collaboration with client
                     1. Accompanies individuals to doctor’s appointments as necessary and facilitates effective medication routines
                        1. Provides education and support to family members and/or significant others of individuals
                           1. Attends psychiatric emergency visits to hospital with individuals, as necessary
                              1. Facilities psycho-educational groups based on specific modalities, utilizing workbooks, grounding exercise, relaxation and breathing techniques to support recovery
                                 1. Provides psycho-educational information based on specific modalities, utilizing workbooks, grounding exercises, relaxation and breathing techniques to support recovery.

1. Review, Follow-up and Referral:

1. Evaluates the individual’s achievement goals from both consumer and case manager perspectives

1. Collaboratively creates a disengagement strategy for the individual providing education on how to reengage the service if required in the future

1. Ensures referrals to the other services are based on individual identified needs

1. Monitors referrals and follows up as appropriate

1. Assists individual to develop both formal and informal supports in the community

1. Documents follow-up plan as per Agency requirements

1. Observes rules of confidentiality and right to privacy in accordance with the Person Health Information Protection Act (PHIPA)
2. Obtains feedback from agencies regarding appropriate referrals in accordance with the PHIPA

1. Assists in conducting surveys as required

1. Community Outreach, Liaison & Collaboration:

1. Assertively reaches out to individuals who may identify or appear to have a service need, ensuring sufficient time and flexibility to initiate a trusting working relationship and offering services in the least intrusive manner possible
2. Provides information to individuals, key supports and service providers regarding access to and type of services and supports available

1. Liaises with police, hospitals, and community service agencies to develop a system of formal and informal supports to accommodate individual needs and relieve pressures
2. Liaises and collaborates with relevant health care services and agencies regarding psychiatric rehabilitation plans for individuals
3. Collaborates and consults with colleagues and health care professionals and/or providers within acute and community care

1. Maintains an up to date list of frequently used agencies, including hours of service, mode of operation, eligibility criteria and policies
2. Assists in the identification of gaps in service and collaborates with relevant community partners and resources to develop plans to meet identified needs
3. Communicates information regarding other relevant community resources to other staff and community partners

1. Advocates for systemic changes regarding social attitudes, rights, laws, etc.

1. Team / Agency Responsibilities:

1. Provides timely and concise communications to team members and other Agency teams regarding circumstances of individuals

1. Enhances required knowledge through continuing education, sharing and disseminating information with Agency staff as appropriate

1. Maintains all required documentation according to Agency standards

1. Attends team meetings and Agency meetings

1. Provides input regarding the development of effective programs and program delivery, including statistical data for ongoing evaluation of program funding

1. Provides supervision and support to placements students and volunteers

1. Assists in orientation of new staff

1. Presents a positive image of Addiction and Mental Health Services-KFLA in the community

1. Supports the philosophy of Addiction and Mental Health Services-KFLA

1. Follows the Policies and Procedures of Addiction and Mental Health Services - KFLA

1. Actively participates in all training as required

1. Leads and actively participates in program evaluation activities, as required.

1. Promotion of Client, Staff and Community Safety

1. Appropriately utilizes best practice techniques and practices contributing to a culture of client, staff and community safety.

1. Proactively supports the Agency’s risk management and infection control systems by tracking occurrences, the presence of symptoms and infectious diseases, checking the environment for safety hazards and increasing risk awareness with clients, other staff and other community.

1. Maintains knowledge of and adheres to the Agency’s infectious control practices

1. Ensures the use of routine precautions and other personal protective equipment as appropriate
2. Participates in relevant safety training such as, but not limited to: WHMIS, hand hygiene, cough etiquette, First Aid/CPR and Crisis Prevention and Intervention

1. Maintains an up-to-date awareness of specific safety risks for individuals in receipt of services, collaborating with clients to mitigate the risks as appropriate

1. Routinely checks the environment for hazardous conditions such as wet floors, poor lighting, condition of walkways, building entrances, etc., taking action to rectify as appropriate
2. Ensures current knowledge of falls prevention techniques, food safety, cleaning techniques and educates clients.

1. Assists clients to take appropriate action regarding any safety hazards identified in their home

1. Instructs and provides ongoing encouragement to clients in the use of proper hygiene and related activities of daily living

1. Acts as a role model to clients and other staff in promoting safety

• University Degree in a health care discipline and unrestricted registration with a regulatory body, as applicable
• Three years relevant experience providing services to individuals who live with a serious mental illness, preferably in a community setting

• Certification in First Aid and CPR an asset
• Applied Suicide Intervention Skills Training (ASIST) an asset
• Experience working within a case management model, preferred

• Knowledge of and ability to apply discipline specific principles and practices to individuals who live with a serious mental illness, within a client-centred approach
• Demonstrated in-depth knowledge of mental health symptoms, issues, psychotropic medications and associated side effects

• Knowledge of issues related to addictions an asset

• Knowledge of and the ability to incorporate best-practices in community support for individuals living with a serious mental illness
• Demonstrated assessment and crisis intervention skills with broad knowledge of emergency mental health and crisis stabilization

• Demonstrated advanced clinical reasoning and decision-making skills

• Ability to effectively utilize community resources and supports to meet the needs of individuals

• Ability to work under pressure within a changing environment

• Working knowledge of the Health Care Consent Act, Mental Health Act, Personal Health Information Protection Act, and other relevant legislation

• Excellent communication and interpersonal skills in order to effectively engage community services and individuals, increasing awareness of services

• Well developed problem-solving, prioritization and conflict resolution skills

• Ability to work autonomously as well as collaboratively in a multidisciplinary team environment

• Basic proficiency in computer skills; MS Office preferred
• Ability to work flexible hours, including weekends

• Must possess a valid Ontario Drivers License, have regular access to a reliable vehicle and provide proof of adequate vehicle insurance
• Required to provide a satisfactory criminal reference check (CRC) with Vulnerable Sector Screening prior to hire

Case Manager Role Variations:

Intensive Case Manager (ICM): the ICM provides case management services as above, incorporating standards listed in the Intensive Case Management Service Standards, identified by the Ontario Ministry of Health (2005)

Transitional Case Manager (TCM): the TCM provides case management services as above with a goal of supporting clients whose needs are of a short-term nature and require 6-16 weeks of service. A TCM will likely see clients more frequently than the ICM due to the limited duration of the service.

Justice Case Manager (JCM): the JCM provides case management services as above to individuals who are actively involved in the criminal justice system who require supports related to their mental health.

Comprehensive Integrated Housing (CI): the CM provides supports to individuals in the CI Housing program using the ACTT model of care and working with an interprofessional team.

Youth Case Manager: The Youth Case Manager provides case management services to individuals 14-25 years of age who would benefit from specialized supports from someone trained with this population.

Case Manager – Community Housing: The Housing Case Manager provides case management to individuals 16 years of age and older who reside in AMHS-KFLA owned homes or in receipt of rent subsidies. This service is in addition to and in collaboration with other internal AMHS-KFLA clinical teams (eg. ACTT, ICM, TCM, etc.) as applicable.

Disclaimer:

Because of the changing nature and work to be done, this job description is not designed to cover or contain a comprehensive listing of the activities, duties or responsibilities required of the incumbent. The incumbent may be asked to perform other duties as required.