Homeless Outreach Counsellor Rotary Transition Centre(Job Id 16988)

Job title: Homeless Outreach Counsellor Rotary Transition Centre

Job ID: 16988

Site: CA:ON:Toronto:St. Michael's Hospital

Category

Work type: Full-Time Temporary

Date posted: September 17, 2026

Salary range: 39.68-49.60

Shift/ hours of work

Description The Homeless Outreach Counsellor works as a part of an inter-professional team in the General Internal Medicine (GIM) supporting the post-hospital visit care plans of patients who are experiencing homelessness.

Reporting to the Manager, Homeless and Outreach Services, the HomelessOutreach Counselloris responsible for time-limited case management, outreach support, and community liaison for people experiencing homelessness. The position will connect with people who are visiting the GIM Department, and will support clients for 90 days after their hospital visit to assist them in following their care plan and connect to long-term social and health supports, aiming to reduce their need for General Internal Medicine Department presentation.

Responsibilities

Establishes and maintains therapeutic rapport with clients to facilitate commitment to adhering to treatment plans;

Effectively assists clients through their ambivalence and resistance to change using evidence/strength based strategies;

Supports clients experiencing homelessness during their General Internal Medicine Department visit and completes intake for longer term case management and outreach

Provides case management support to clients to assist them in meeting their post-visit care plans and provide support in times of crisis;

Provides outreach support to clients to help access resources, connect with agencies and health care providers and improve community connections/integration;

Works collaboratively with GIM staff and physicians to ensure care plans meet client needs and facilitate coordinated transitions of care and client discharges back to the community.

Works diligently to foster excellent relationships with internal and external partners;

Provides outreach services to clients who are unwilling or unable to attend office based appointments;





Engages in periodic evaluation and review of care goals and re-negotiates goals as is appropriate;

Participates in client case management meetings when requested by either the client or primary care team;

Records all client interactions in an objective and accurate manner that reflects organizational protocols and established regulatory practices;

Document all stages of the care transition and coordination process clearly, accurately and concisely.

Builds partnerships with community agencies including developing and implementing referral pathways;

Acts as a liaison with the community agencies to ensure appropriate client referrals;

Acts as an advocate on behalf of the registered client when deemed necessary;

Engages in day-to-day liaison activities with relevant professionals and community members;

Promotes and maintains community relationship with key stake holders; i.e. substance use and harm reduction focused organizations, primary care providers, Probation, Pharmacies, Mental Health and others;

Strengthen internal partnerships with the SMH outreach services;

Collaborate with in-patient units and outreach services if client is admitted to facilitate coordinated transitions of care and client discharges back to the community.

Participates in ongoing meetings with GIM team and Outreach Services staff for case reviews and reporting

Spearhead educational opportunities that increase the knowledge capacity of the General Internal Medicine Department staff to manage the needs of patients experiencing homelessness;

Works in collaboration with research staff to facilitate an evaluation of providing post-visit care planning and outreach support as an intervention for people experiencing homelessness.

Qualifications

Must havea post-secondary qualification in: Social Service Work, Addictions and Mental Health, Community Service Work,



Counselling or a related discipline;

Must have a minimum 3 years' experience working with people experiencing homelessness

Must have extensive knowledge of social service resources in the community.

Must have experience working in an independent outreach position, meeting with clients alone in the community or in their homes or shelters;

Must have experience in case management, and goal-setting;

Must have experience in engaging people facing significant barriers to accessing health, social services and housing;

Solid organizational, coordination and administrative skills;

Highly skilled in crisis management and intervention with clients;

A commitment to a cooperative approach to problem solving;

Ability to work independently and as part of a multidisciplinary team;

Ability to respectfully and meaningfully engage clients experiencing homelessness; demonstrated understanding of the unique issues and barriers facing this population;

Awareness of HIV/AIDS, HCV, harm reduction and related issues and their impact on clients experiencing homelessness

Knowledge of addictions treatment modalities an asset;

Experience working in a interprofessional team;

Excellent written and verbal communications skills;

Experience working with diverse communities with complex psycho-social needs including concurrent disorders;

An understanding of the impact of the social determinants of health and a commitment to working collaboratively with patients to mitigate these;

Unity Health Toronto is committed to creating an accessible and inclusive organization. We strive to provide a recruitment process that is barrier-free and in compliance with the Accessibility for Ontarians with Disabilities Act (AODA) and the Ontario Human Rights Code. We understand that you may require an accommodation at any stage of the recruitment process.

When you are contacted, please inform the Talent Acquisition Specialist and we will work with you to meet your accommodation needs. We want to emphasize that all accommodation requests are handled with the utmost confidentiality, respecting your privacy and dignity.

📌 Homeless Outreach Counsellor Rotary Transition Centre (Winnipeg)
🏢 St. Michael's Hospital
📍 Winnipeg