The centralized transition planning team provides in-depth assessments and discharge planning for patients with complex health and social needs. Using a case management approach the team is mobile, supporting patients throughout the entirety of their journey in hospital; from the emergency department, in acute care and back to community. The team works in collaboration with the HNHB CCAC, Health Links, the Community Connector and unit-based clinical teams to ensure comprehensive supports are in place in the community when the patient is discharged from hospital so that the patient has a smooth and successful transition.

The centralized transition team reports to the manager of the Office of Community connections and transitions

- Bachelor or Masters Degree in Clinical Social Work from an accredited School of Social Work
- Current Certificate of Registration with the Ontario College of Social Workers and Social Service Workers
- Demonstrated expertise in complex geriatric assessment, and developing individualized coordinated care plans for seniors living with multiple chronic diseases, frailty, and cognitive impairment.
- Minimum of 3-5 years clinical experience in working with older adults in an in-patient setting, including experience with discharge planning.
- Expert knowledge of legislation that impacts on seniors, including the Substitute Decision Makers Act and issues related to capacity and decision-making..
- Expert knowledge of community-based resources for seniors and people with multiple medical issues.

7.Ability to creatively problem solve and facilitate change.

- Understanding of the social determinants of health, and the social consequences and risk factors associated with aging.
- Demonstrated strength in case management, consultation, and teamwork.
- Demonstrated proficiency in report writing relating to assessment, and consultation.
- Excellent written and verbal communication alongside strong interpersonal skills
- Understanding of diversity as it affects different populations and service delivery




- Evidence of self-motivation, enthusiasm, and flexibility

15. Demonstrated commitment to ongoing learning The Social Worker functions as a valuable member of the interdisciplinary team and provides care to frail, complex senior patients. The role has a dual focus: to prevent avoidable admissions by liaising with community supports; and to provide early assessment and intervention associated with best practice for geriatric patients.

The Social

Worker provides time-sensitive case management for admitted patients, including leadership in the coordination of transitions across different levels of care within the hospital system and back to community, as well as providing consultation/liaison to other caregivers and community agencies. The SW assesses, plans, monitors and evaluates client goal achievement. In particular, the SW practices by combining education and related clinical experience to offer patients and their caregivers support, assessment and resource support for successful discharge with an emphasis on addressing social justice and self-determination by enhancing linkages with hospital and community services and acts as an advocate for the frail seniors they serve and where appropriate, in partnership with community resources. In addition, the Social worker will actively participate in continuing professional development opportunities, skilled practice and program committees & initiatives that support patient care, clinical practice, education and research as approved by the manger. Days, weekends, evenings; and holidays.

This position is temporary until June 2027.

Hamilton Health Sciences fosters a culture of patient and staff safety,



whereby all employees are guided by our Mission, Vision, Values, and Values Based Code of Conduct. Hamilton Health Sciences is a teaching hospital and all staff and physicians are expected to support students and other learners.

To be considered for this opportunity applicants must apply during the posting period. All internal and external applicants may ONLY apply via the Careers website. This job posting is for an existing vacancy.

Hamilton Health Sciences is an equal opportunity employer and we will accommodate any needs under the Canadian Charter of Rights and Freedom, Accessibility for Ontarians with Disabilities Act and the Ontario Human Rights Code. Hiring processes will be modified to remove barriers to accommodate those with disabilities, if requested. Should any applicant require accommodation through the application processes, please contact Human Resources at (phone hidden), Ext. 46947 for assistance.

If the applicant requires a specific accommodation because of a disability during an interview, the applicant will need to advise the hiring manager when scheduling the interview and the appropriate accommodations can be made.

This competition is open to all qualified applicants, however, qualified internal applicants will be considered first. Past performance will be considered as part of the selection process. If you are a previous employee of Hamilton Health Sciences, please note: the circumstances around an employee's exit will be considered prior to an offer of employment. Proficiency in both Official Languages, French and English, is considered an asset.

If this position is temporary, selection for this position will be as per the outlined Collective Agreements:

Article 30 (k), CUPE Collective Agreement

Article 10.7 (d), ONA Collective Agreement

Article 13.01 (b) (ii), OPSEU 273 Collective Agreement

Article 14.04, OPSEU 209 Collective Agreement

Article 2.07 and Article 13, PIPSC RT Collective Agreement

📌 Social Worker BSW (Ontario)
🏢 Hamilton Health Sciences
📍 Ontario