Description
POSITION TYPE FULL-TIME
JOB SUMMARY
Siloam Mission’s Medical Transitional Care Unit (MTCU) is a 32-bed, time-limited transitional care facility supporting individuals experiencing homelessness who have medical needs that do not require hospitalization. The MTCU integrates housing, medical care, and social supports to improve health outcomes and support transitions to permanent housing.
Guided by person-centered, strengths-based, and trauma-informed practice, and rooted in harm reduction and Housing First principles, the MTCU operates through a holistic and multidisciplinary approach.
The Intake & Transition Worker is the primary point of contact for referrals and admissions to the MTCU and plays a key role in supporting resident transitions both into and out of the unit. This role coordinates intake, facilitates connections to the interdisciplinary care team and internal Siloam Mission programs. It also supports residents who exit the unit prior to securing housing to connect with appropriate community and housing supports. The Intake & Transition Worker does not hold an ongoing caseload, providing brief, time-limited casework support.
KEY DUTIES & RESPONSIBILITIES
Intake, Referral & Admissions Coordination
- Serve as the primary contact for MTCU referrals from hospital social work teams (including inpatient units and emergency departments), as well as community-based referral sources
- Receive, review, and triage referrals to assess eligibility, urgency, and appropriateness in collaboration with clinical and program leadership
- Communicate clearly and promptly with referral sources regarding admission decisions, waitlists, and next steps
- Coordinate intake processes, including gathering relevant documentation, consent, background information, and verifying accuracy of information
- Facilitate smooth admissions by preparing residents for entry into the unit and orienting them to the MTCU environment, expectations, and supports
Resident Transition & Early Engagement
- Support newly admitted residents to connect with the interdisciplinary care team
- Provide early engagement, orientation, and brief support to help residents understand available services and begin goal-setting
- Identify immediate needs and risks during intake and transition periods, escalating concerns to appropriate clinical or supervisory staff
- Support continuity of care during transitions into the unit from hospital or community settings
Transition Planning & Exit Support
- Support residents who leave the MTCU prior to securing permanent housing by connecting them with appropriate housing, medical, and community-based supports in collaboration with the case worker
- Provide short-term transition planning, referrals, and system navigation to reduce gaps in care and housing pathways
- Coordinate with internal teams and external partners to support continuity during planned or unplanned exits
Internal Systems Navigation & Collaboration
- Act as a key connector between the MTCU and other Siloam Mission programs and services, supporting referrals and warm handoffs within the organization
- Maintain strong working relationships with hospital social workers, community agencies, housing providers, and internal stakeholders
- Participate in interdisciplinary team meetings, care conferences, and program planning discussions as required
- Share relevant resident information explicitly in accordance with consent, privacy legislation, and organizational policies
Brief Casework, Harm Reduction & Crisis Response
- Provide brief, time-limited casework support as needed
- Offer harm reduction education and support aligned with resident readiness and organizational practice
- Identify and respond to mental health crises or safety concerns in collaboration with clinical staff and external crisis services
- Utilize trauma-informed, de-escalation, and non-punitive approaches when responding to distress or crisis
- Recognize personal limits and seek supervisory or clinical support as needed
Administrative & Program Support
- Complete timely, accurate, and objective documentation related to intake, referrals, transitions, and resident interactions
- Maintain electronic and paper records in accordance with departmental procedures
- Track and report intake, referral, and transition data as required for program monitoring and funding
- Attend and participate in department and organizational meetings, training, and professional development
- Support leadership to improve operational policies and procedures
- Perform other related duties as assigned
EDUCATION & EXPERIENCE
- Completion of a diploma/degree in a health or human service field e.g. social work, psychology; a combination of education and experience may be considered
- Certification in or demonstrated knowledge of NVCI (Nonviolent Crisis Intervention), ASIST (Applied Suicide Intervention Skills Training), CPR/First Aid, Mental Health First Aid (MHFA)
- Experience working with individuals experiencing homelessness, complex health needs, mental health challenges, and/or substance use
- Demonstrated experience in intake, assessment, system navigation, or care coordination
- Familiarity with hospital discharge planning, community referrals, and housing pathways is an asset
- Training or experience in trauma-informed care, harm reduction, crisis response, Motivational Interviewing, or related approaches is an asset
- Valid Class 5F driver’s license, acceptable driver’s abstract, and reliable vehicle required
- Lived experience an asset
KNOWLEDGE/SKILLS/BEHAVIORS
- Strong knowledge of community resources related to homelessness, poverty, health, mental health, and substance use
- Knowledge of community and housing resources and referral pathways
- Demonstrated commitment to harm reduction, trauma-informed, anti-oppressive, anti-racist, and culturally safe practices
- Understanding of Indigenous history, colonization and its impacts on Indigenous peoples
- Exceptional interpersonal, verbal and written communication skills
- Outstanding relationship-building skills and strong active listening abilities to effectively understand and respond to client needs
- Strong de-escalation, mediation, critical thinking, and problem-solving abilities
- Outstanding attention to detail, organizational and time management skills
- Skilled at prioritizing and multitasking
- Exceptional documentation skills
- High level of integrity, confidentiality, and accountability
- Highly developed understanding of and proven ability to communicate appropriate professional boundaries
- Ability to collaborate and coordinate effectively with multiple departments and functions to support client-centered outcomes
- Ability to work effectively in high-change change environments with patience and resilience
- Demonstrated ability to analyze and measure system performance and commitment to continuous improvement
- Proficiency in Microsoft Office (Word, Excel, Outlook)
RELATIONSHIP
- Building professional and respectful relationships with residents
- Collaborate closely with MTCU interdisciplinary team members
- Work in partnership with hospital social work teams, community agencies, and housing providers
- Liaise with internal Siloam Mission programs to support coordinated care and service access
WORKING CONDITION
- Hours of Work: 10:30 a.m. – 9:00 p.m. rotational schedule (4 days on, 4 days off) averaging 80 hours biweekly
- May be required to transport residents to appointments or services in personal vehicle
- Work may involve exposure to substance use, mental health crises, medical needs, and emotionally demanding situations
- Hazardous conditions could potentially include unpredictable or risky behaviours from community members
Please send a cover letter and a resume to employerrep@abcentre.org.
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