IPC Clinical Care Coordinator

internal/external posting

job title: IPC Clinical Care Coordinator

job ID #: IHS IPCCCC 23-0116

department: Integrated Health Services

reports to: Supervisor, Health Bus

salary range: CS4 $31.64 – $39.26

status: Permanent, Part-Time

hours: 30 hours per week

Who we are:

Sherbourne is a leading provider of quality health care and transformative support to people who face social, economic, and other systemic barriers. Our mission is to advance the equity and quality of care and services and to improve health for underserved communities.  This is done through primary health and chronic disease services; health promotion and education; outreach and social supports; and mental health services.

Sherbourne provides innovative health care and social services to the diverse urban population of southeast Toronto.  While our doors are open to everyone, we focus on people who are homeless or under-housed, 2SLGBTQ, and newcomers to Canada. We are funded by the Ministry of Health, Toronto Central LHIN, Ministry of Child and Youth Services, City of Toronto and many generous companies, groups, and individuals.

Working at Sherbourne

At Sherbourne Health, we care about our staff and recognize that our biggest strength is our people. We have a solid commitment to life-long learning which is demonstrated through our professional development program. We invest in collective work and staff training to improve client care. We supplement this by creating a low-barrier work environment built on equity and respect, while working together in caring, cohesive teams and providing opportunities for advancement.

we believe in work-life balance and offer:

  • A competitive salary.
  • Membership in Healthcare of Ontario Pension Plan (HOOPP).
  • Four weeks of vacation per year (to start).
  • Four personal days per year.
  • An extended healthcare and dental package.
  • Long-term disability insurance.
  • Life insurance.
  • An employee assistance plan.
  • A generous professional development plan: up to $1300 to be used towards learning activities.
  • Six fully paid professional development days per year – related to position/responsibilities.

 about the role:

The IPC Clinical Care Coordinator helps clients navigate the health system and provides regular supportive counselling and case management to Health Bus clients who are homeless, precariously housed and/or who have mental health and substance use issues.

The IPC Clinical Care Coordinator liaises with multiple stakeholders, including clients, primary care providers, the Acute Respite Care program and local community organizations to facilitate care coordination and case management. The IPC Clinical Care Coordinator also provides guidance and leadership to the IPC System Navigators.

 Day to day responsibilities:

 Clinical Care Coordination Services

  • Works on the Health Bus to connect with clients who are homeless, precariously housed, and/or who have mental health substance use issues
  • Acts as a resource for, and works closely with, the other members of the IPC team and community partners to assess needs and identify relevant services and support options as well as developing and/or collaborate on the development of coordinated care plans
  • Provides counselling and case management services utilizing a variety of techniques, therapeutic modalities and approaches that are trauma-informed, strength-based, culturally sensitive and appropriate to client’s issues
  • Provides holistic assessment and support services to individuals presenting with mental/ emotional health or substance use issues
  • Ensures that appropriate support plans are developed, implemented, and evaluated in collaboration with clients, monitoring client progress adjusting plans as necessary
  • Follow-up with clients serviced on the Health Bus at Sherbourne Health Centre and in the community
  • Provides supportive counselling to service users in distress, when necessary
  • Operate the Health Bus on a regular basis
  • Provide crisis intervention, systems navigation, accompaniments with clients and make appropriate referrals
  • Attend and arrange case coordination meetings as required
  • Facilitate client referrals for internal or external community services
  • Distribute harm reduction supplies and naloxone as required

Health Promotion, Education and Advocacy

  • Provide appropriate client advocacy services as directed by the client
  • Collaborate and consult with multidisciplinary staff, partnering organizations and broader community to facilitate comprehensive care
  • Engage in evidenced-based practice and ongoing learning
  • Advocate for individual client needs to ensure access to effective care, follow-up and resources from both an individual and systemic level;
  • Collaborate with colleagues to identify population trends, develop research questions and/or conduct research studies
  • Facilitate knowledge translation by educating colleagues on topics related to client care
  • Initiate and/or participate in systemic advocacy activities directed at achieving health equity by improving the social determinants of health, eliminating stigma and developing healthy public policy

Administrative Duties

  • Contribute to overall policy and program directions
  • Operates the Health Bus on a regular basis, driving the health bus to weekly stops, maintenance appointments, etc.
  • Participates in ongoing evaluation of programs and service delivery
  • Operates within established policies and procedures
  • Maintain accurate client records of client encounters using Accuro EMR
  • Participate in team and organizational meetings, committees, special events, etc.
  • Understands and works within the Occupational Health and Safety Act (OHSA), Personal Health Information Protection Act (PHIPA), Accessibility for Ontarians with Disabilities Act (AODA), the Ontario Human Rights Code and other relevant legislation.
  • Demonstrates a commitment to a healthy and safe workplace for self and others (staff, patients, families, etc.) by taking all reasonable precautions and working in compliance with Sherbourne-related policies, health and safety legislation and best practices.
  • Other duties as required

To thrive in this role, you’ll need


  • Master of Social Work degree or some combination of relevant education and experience in a similar health discipline
  • 3-5 years’ experience working in the community mental health and harm reduction sectors, or an equivalent blend required.
  • Current registration with a regulated professional body (e.g. OCSWSSW) is an asset
  • Expertise in providing counselling and case management to individuals who are experiencing or have experienced a complex history of mental health concerns, substance use, and/or homelessness required
  • Recent experience working in a community setting doing outreach required
  • Experience and knowledge of the social determinants of health, the health care system and the social support system as they relate to the needs of homeless and precariously housed individuals as well as individuals who may have substance use issues
  • Experience building relationships with health care providers and organizations
  • Experience working in a multi-disciplinary team and collaborating with teams on the care of clients
  • Experience in mental health supports, crisis de-escalation, and safety assessments
  • Demonstrated initiative and experience working independently with minimal supervision
  • Recent experience working in a community setting and outreach preferred
  • Demonstrated EMR (ideally Accuro) and software skills (MS Teams, PowerPoint, Excel).
  • Valid G-Class Driver’s License and Driving Record in good standing to operate the Health Bus required.

skills and abilities:

  • Thorough knowledge and experience of harm reduction, trauma-informed approaches, addictions and mental health
  • Broad knowledge of dual diagnosis & concurrent disorders as well as alternative models and approaches to mental health treatment and trauma informed care
  • Knowledge of criminal justice system, Ontario Works, and the Ontario Disability Support Program
  • Ability to work within an anti-oppression, trauma informed framework; understands and appreciates the diversity of our client, staff population and community
  • Excellent oral and written communication skills; strong computer skills and experiences using database software
  • Ability to carry out duties independently while maintaining accountability

conditions of employment:

  • Offer of employment is contingent upon satisfactory outcome of background checks i.e., professional references, education verification, criminal background check, vulnerable sector check, and insurable by Sherbourne’s designated insurance provider..
  • Understands and works within the Occupational Health and Safety Act (OHSA), Personal Health Information Protection Act (PHIPA), Accessibility for Ontarians with Disabilities Act (AODA), the Ontario Human Rights Code and other relevant legislation.

working conditions:

  • Ability to work a fixed schedule and have flexibility to work evenings and weekends.
  • This position will work on site at Sherbourne Health, on the Health Bus, and in the community with clients where needed.

To apply:

Please forward a cover letter and resume quoting Job ID # IHS IPCCCC 23-0116 to myjob@sherbourne.on.ca by 5:00 pm on January 29, 2023.

Sherbourne is dedicated to building an organization that reflects the diversity of our clients and the communities we serve. This includes diversity in languages spoken, culture, race, sexual orientation, and gender identity. Requests for accommodation due to disability can be made at any stage in the recruitment process.

We thank all applicants for their interest but only those selected for further consideration will be contacted.

BOLD.                  KIND.                   REAL.                   OPEN.                   WE