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Job postings: Allied Health

Social Worker (SCOPE Mental Health Navigator) - Strategy & Integration - Temporary Full-Time (until approx. March 2023) (220304)

Toronto, ON, CA Posted: 2/11/2022 11:56:36 AM

We currently have a Temporary Full-Time (until approx. March 2023) opportunity for a Social Worker (SCOPE Mental Health Navigator) in the Strategy & Integration department at our Bayview Campus.

Hours of Work:

Weekdays, Days, 8 hrs, as per schedule

This posting is for a 1.0 FTE Mental Health Navigator position. The incumbent is responsible for providing navigation support for primary care providers related to Mental Health as part of SCOPE (Seamless Care Optimizing the Patient Experience). SCOPE is a partnership between hospital, Home and Community Care, and primary care providers. The SCOPE service is a virtual interprofessional team that facilitates greater access for primary care providers for their patients. SCOPE is integral to the strategy of the hospital as well as the North Toronto Ontario Health Team. The incumbent works closely with the SCOPE Nurse Navigator, and develops relationships with primary care providers, mental health and addictions providers in North Toronto and across the city, and also other SCOPE programs in the Toronto Region. The incumbent will be closely linked and integrated with Family Navigation Project (FNP) at Sunnybrook, a program that provides youth and their families with support and expert navigation of the mental health and addictions service system. A dual reporting structure will be in place for this position (SCOPE and FNP).

Summary of Duties

The Mental Health Navigator, working within the recovery and guided self-help models of care, will support community based Primary Care Practitioners and work closely with consulting psychiatrists at Sunnybrook Health Sciences Centre and Family Navigation Project. The role will be of interest to a Social Worker with mental health experience.

The role requires diverse skills including:

  • systems navigation,
  • telephone and in person clinical consultation,
  • the ability to triage for acuity, diagnosis and treatment recommendations,
  • assessment for acute/crisis needs and knowledge of guided self-help either as the treatment of choice or as a bridge to more appropriate treatment.

As a member of the SCOPE interprofessional team, the individual will contribute to the development and review of integrated primary care including the provision of appropriate data and model development.

Tasks Include:

  • Primary responsibility is to serve as a point of access to connect primary care providers to appropriate supports related to Mental Health and Addictions
  • Respond to all calls and emails made to SCOPE by the primary care providers and their administrative assistants related to Mental Health and Addictions
  • Understand and clarify primary care provider / patient concerns and request for support; assess patients for the purpose of evaluating the need for service, the nature of the problem, and formulating recommendations or treatment plans
  • Liaise with appropriate community agencies
  • Establish contact with members of the interprofessional team and community agencies to obtain, provide or exchange information relating to patients' psycho-social functioning and health care
  • Collect relevant patient information where appropriate for assessment and database entry (Patient Name, DOB, HC#)
  • Collaborate with the health care team to improve patient care as they transition through the health care system
  • Enhance work flow and communication pathways between hospital, primary care and community care by identifying barriers to care and work towards creating new care pathways to promote and optimize seamless care for the client. This includes the clarification of referral criteria and identification of the resource that will best suit the health care need
  • Improve communication and collaboration between consultants and primary care services by assisting primary care provider staff in the compilation of referral packages and follow-up of referrals
  • Collect data / outcomes for research and evaluation for each referral / patient – database entry forms to be completed with each referral and submitted to the evaluation team on a regular basis
  • Review available/relevant information to determine assessment and care planning
  • Provide primary care providers or their staff with clinic/referral information
  • Navigate hospital clinics and resources (if available) that will assist primary care provider with managing client medical, functional, cognitive, psychosocial conditions
  • Adhere to established productivity benchmarks
  • Responsible for outreach efforts to establish and maintain positive working relationship with key customers
  • For a small number of patients requiring interim supports and counselling, support patients through regular, patient-centered follow-up, including home visits to engage and empower patients
    • Identify appropriate and credible resources responsive to patient needs taking into consideration culture, language, reading level, and health literacy
    • Coordinate patient care between multiple health and social providers within our catchment area and leverage Sunnybrook programs and services
    • Implementing an intervention plan with patients, family members, significant others, and the multi-disciplinary team for the purpose of facilitating changes in behavior, attitudes, feelings and/or the environment
  • Taking into account each patient’s values, preference and circumstance, support the development of patient-centered goals
  • Demonstrate responsiveness to patient needs within scope of practice and professional boundaries
  • Encourage active communication between patients/families and health care providers to optimize patient outcomes
  • Use goal setting and action planning techniques to encourage positive changes for patients
  • Provide appropriate patient education in the community
  • Support patient self-management techniques


  • Completion of a Masters Degree in Social Work (M.S.W) or equivalent required
  • Registration with the Ontario College of Social Workers and Social Service Workers required
  • Membership in the Ontario Association of Social Workers preferred
  • Two (2-3) years experience working with an interprofessional team
  • Strong knowledge of mental health resources and previous mental health work experience
  • Ability to work independently but seek consultation when needed
  • Excellent verbal and written communications skills
  • Excellent interpersonal, time management and organizational skills
  • Excellent problem solving skills
  • Research experience /education an asset
  • Student education/supervision an asset
  • Knowledge of policies, legislation, program's and issues related to social welfare institutions and services
  • Computer literacy required

Qualified candidates are invited to submit their cover letter and resume (in one document) quoting 220304 to:

Human Resources
Sunnybrook Health Sciences Centre

To apply, please click "Apply for Position" at the bottom of this page.

Sunnybrook Health Sciences Centre is committed to providing accessible employment practices that are in compliance with the Accessibility for Ontarians with Disabilities Act (AODA). If you require accommodation for disability during any stage of the recruitment process, please indicate this in your cover letter.

Sunnybrook Health Sciences Centre is strongly committed to inclusion and diversity within its community and welcomes all applicants including but not limited to: visible minorities, all religions and ethnicities, persons with disabilities, LGBTQ persons, and all others who may contribute to the further diversification of ideas.

Please be advised that in order to be eligible for employment at Sunnybrook, all new hires must have received the full series of a COVID-19 vaccine or combination of COVID-19 vaccines approved by Health Canada (e.g., two doses of a two-dose vaccine series, or one dose of a single-dose vaccine series); AND have received the final dose of the COVID-19 vaccine at least 14 days ago. Medical exemptions or any other kind of requested exemption based upon the Hospital’s obligations pursuant to the Ontario Human Rights Code will be considered on a case-by-case basis.