Job Description

Posting closes: January 27, 2026 at 5:00pm



We are recruiting for an

INTENSIVE GERIATRIC SERVICE WORKER

This is a regular full-time position to fill an existing vacancy (35 hours per week Monday to Friday 9am to 5 pm) based at 55 King St. W. Kitchener and at 1145 Concession Rd. Cambridge.*


The Intensive Geriatric Service Worker (IGSW) plays a critical role at the Canadian Mental Health Association Waterloo Wellington (CMHA WW) in supporting seniors with complex needs to safely and successfully live in the community. Reporting to the Manager, Seniors Services, this position provides intensive case management, service coordination, advocacy, and system navigation for older adults transitioning from emergency departments, acute care, or specialized geriatric services.



Working within an integrated service delivery model, the IGSW collaborates closely with seniors, families, primary care providers, hospitals, other CMHA WW teams, and community partners across the Waterloo Wellington service system. Through proactive outreach, coordinated care planning, and strong advocacy, the role ensures seniors are connected to appropriate supports, experience smooth transitions, and receive responsive, person-centered care aligned with their goals, strengths, and needs.

Responsibilities include:

Intensive Support & Care Transitions

Provide intensive, time-limited support to seniors transitioning from emergency departments, acute care, or specialized geriatric services to community-based supports. Collaborate with seniors, families, primary care providers, Geriatric Emergency Management Nurses, Specialized Geriatric Services, and community partners to support and implement individualized care plans. Respond promptly to referrals from tertiary services, including hospital discharges and emergency departments, to ensure timely access to appropriate supports. Engage seniors who experience barriers accessing services and support them in addressing immediate needs such as shelter, food security, and urgent medical care.

Direct Service Delivery & Case Management

Implement, coordinate, and integrate services and resources that support seniors to remain safely in their homes and communities. Provide outreach and ongoing support to seniors and their families or support networks, adapting interventions based on evolving needs. Develop, implement, and monitor individualized intervention and support plans, including formal documentation where required (e.g., Form 2). Identify and reduce barriers to accessing services, promoting informed choice and autonomy for seniors. Coordinate supports and resources to advance agreed-upon goals and regularly evaluate and adjust service plans to ensure effectiveness.

Service Coordination & Navigation

Serve as a primary point of contact for seniors and families, coordinating services across health, mental health, social, and community-based systems. Facilitate service planning meetings and case conferences to review progress, address challenges, and revise goals as needed. Work collaboratively with CMHA WW teams and external service providers to ensure seamless, integrated service delivery. Support seniors and their families in navigating complex health and social service systems.

Crisis Intervention & Planning

Develop individualized crisis plans in collaboration with seniors, families, and professional supports. Provide crisis intervention, stabilization, and follow-up as required. Regularly review and update crisis plans to reflect changing needs and ensure shared understanding among identified supports. Ensure crisis plans are communicated to appropriate community partners and natural supports, in accordance with client consent.

Advocacy & Family/Community Engagement

Advocate with and on behalf of seniors to support access to services, resources, and rights-based supports. Assist seniors in clarifying goals, needs, and desired outcomes, and support the development and evaluation of advocacy plans. Provide education and information to families, caregivers, and community members to enhance understanding and support. Facilitate collaboration and communication between seniors, families, primary care providers, and community partners. Participate on community committees or working groups, representing the service perspective as directed by the Manager.

Documentation, Quality & Team Collaboration

Complete accurate, timely documentation in accordance with CMHA WW policies, standards, and confidentiality requirements. Conduct standardized assessments and maintain accurate client records within electronic systems. Participate in quality improvement, evaluation, and service planning initiatives. Engage actively in team meetings, planning activities, and collaborative service delivery. Adhere to CMHA WW health and safety policies, including completion of mandatory training requirements. Uphold CMHA WW's Mission, Vision, Values, and commitment to service excellence and client safety.

Qualifications:

Completion of an undergraduate university degree in social work, gerontology, psychology, or a related health or social services discipline. Relevant training such as P.I.E.C.E.S., Gentle Persuasive Approaches, or Montessori-based approaches is considered an asset. Three to five (3-5) years of experience providing community-based support services to seniors, including individuals with complex geriatric, mental health, or concurrent needs. Previous experience working with community-based service models, emergency department pathways, and Alternate Level of Care (ALC) considerations, including active participation within interdisciplinary teams and integrated service systems. Demonstrated ability to apply person-centered and recovery-oriented approaches when supporting seniors with complex needs, including mental health, addictions, or concurrent disorders. Sound knowledge, skills, and clinical judgment to provide intensive geriatric services, informed by an understanding of societal, cultural, and gender-related factors that influence seniors' care experiences, including crisis intervention and transition support. Strong verbal and written communication skills, combined with excellent interpersonal abilities to work respectfully and effectively with seniors, families, physicians, and community partners across diverse settings. Excellent problem-solving abilities, organizational skills and attention to detail; including the ability to prioritize competing tasks and manage shifting priorities effectively. Proficiency in Microsoft Office Suite (Outlook, Word, PowerPoint, Excel), with familiarity using technology, electronic documentation systems, and online resources. Valid G Class driver's license, access to a reliable personal vehicle, and appropriate insurance Embodies and promotes CMHA WW's core values of Mutual Respect, Integrity, Accountability, Excellence, and Innovation in all professional interactions and decision-making.

Qualified applicants are invited to submit a resume and cover letter outlining how your skills, qualifications and experience meet the position requirements.

CLASSIFICATION AND RATE OF PAY: Level 5 (OPSEU) - $33.07 to $40.30 per hour

CMHA WW, as an equal opportunity employer, embraces diversity and is committed to creating an inclusive workplace. Our goal is to attract, develop and retain talented employees from diverse backgrounds, allowing us to benefit from a wide variety of experiences and perspectives. We welcome applications from all qualified persons.

* We do not use AI in our screening process.