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St. Joseph's Health Centre, Toronto

Social Worker, Geriatric Navigator

Toronto, ON, Canada

Temporary

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Job details

Job type: Temporary
Apply by: Nov 22, 2026
Experience: Minimum of 2 years experience in working in a geriatric population;
Posting language: English
Posted: Oct 23, 2026

Original job description

This position will function as a member of the Medicine Program, including Geriatrics and General Internal Medicine working collaboratively with the Geriatric Medicine consultation team at St. Joseph’s Health Centre (SJHC). The role of the social worker is to provide assessment, coordination and provision of services to geriatric clients/families including crises intervention and short-term management. To help with reducing emergency department (ED) readmissions and admission to Long Term Care (LTC). The Navigator, in collaboration with the inter-professional treatment team in hospital, the social worker will provide short term follow-up to clients of the program to maintain clients at their highest level of functioning in the community.

Major Responsibilities

Coordinate and support post-discharge care of geriatric patients in collaboration with discharge planner and general medicine team;
Case conference with other providers involved in patient’s care as appropriate;
Develop short term follow up plan for high risk readmission patients;
Ability to develop appropriate recommendations, and make appropriate community referrals as necessary (such as community health centres, geriatric outreach teams);
Facilitate co-ordination of services with community Health Centre (CHC) in patient’s postal code. Liaise and link with community Geriatric Outreach team as appropriate;
Work collaboratively with SJHC's Seamless Care Optimizing the Patient Experience (SCOPE) navigator to address gaps to support family physicians to get timely and if needed urgent advice from SJHC's Geriatric Medicine Team;
Develop, monitor and track key performance indicators and quality improvement metrics in consultation with the Medicine Program leadership;
Obtains all relevant information to assess, analyze, plan, implement and evaluate a plan of care/action to coordinate client needs;
Ability to and or willing to learn how to complete comprehensive geriatric assessments;
Practice in a manner that prioritizes safety, including the safety of oneself, patients, families, and colleagues;
Working knowledge of the regulated Health Profession act, mental health act, health care consent act and substitute decision act.

Qualifications

Must be currently licensed by and in good standing with the Ontario College of Social Workers and Social Service Workers (OCSWSSW) for practice in all applicable clinical areas
Must hold a Masters Degree in Social Work
Current BLS (or willingness to complete within probationary period)
Minimum of 2 years experience in working in a geriatric population;
Experience working in the community service is preferred;
Expertise in caring for vulnerable patients with multiple-comorbidities would be preferred;
Experience with virtual care would be an asset;
Access to a vehicle required.
Excellent communication, critical thinking, and interpersonal skills
Proven flexibility and adaptability in a fast-paced environment
Excellent time management, organizational and prioritization skills as relates to patient care
Demonstrated advocacy, commitment to and involvement with profession preferred (e.g. involvement with professional association, representation on relevant committees)

Potential candidates who do not meet all preferred qualifications are still encouraged to apply.

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.

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More about this job

Responsibilities

Coordinate post-discharge care and short-term follow-up for geriatric patients, including high-risk patients, to support community functioning and reduce emergency department readmissions and long-term care admissions. Collaborate with hospital and community providers, assess client needs, coordinate referrals and services, and monitor quality and performance metrics.

Requirements

Requires a Master of Social Work degree, current registration in good standing with the Ontario College of Social Workers and Social Service Workers, current BLS certification or willingness to obtain it during probation, and at least two years of geriatric experience. Community service experience, care of medically complex and vulnerable patients, virtual care experience, access to a vehicle, and strong communication, critical-thinking, organizational, and time-management skills are also sought.

Skills

Geriatric Assessment
Care Coordination
Discharge Planning
Crisis Intervention
Short-Term Case Management
Community Referrals
Interprofessional Collaboration
Case Conferencing
Patient Advocacy
Quality Improvement
Performance Metrics Tracking
Communication
Critical Thinking
Time Management
Organization
Adaptability

Visa sponsorship

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Keywords

Social Work
Geriatrics
Geriatric Medicine
General Internal Medicine
Master of Social Work
Ontario College of Social Workers and Social Service Workers
BLS
Comprehensive Geriatric Assessment
Crisis Intervention
Short-Term Follow-Up
Discharge Planning
Care Coordination
Community Health Centres
Geriatric Outreach Teams
Interprofessional Treatment Team
Seamless Care Optimizing the Patient Experience
SCOPE Navigator
Long-Term Care
Quality Improvement Metrics
Key Performance Indicators
Health Profession Act
Mental Health Act
Health Care Consent Act
Substitute Decisions Act
Virtual Care
Patient Advocacy
Vulnerable Patients
Multiple Comorbidities

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