Case Manger, Prevention and Transition, Heart to Home Program

POSITION SUMMARY:

The Case Manager, Prevention and Transition, supports newly housed individuals as well as individuals at risk of eviction. This role provides intensive, mobile, client-centered support to ensure successful housing stabilization, prevents eviction, and improves long-term housing outcomes. The incumbent will be responsible for ensuring that participants with complex needs receive the support necessary to help them reintegrate into the community, achieve housing stability, and reach their personal goals. The Case Manager, Prevention and Transition, is expected to maintain a caseload established by the program, which could include referrals from the “Co-ordinated Access Table”, local hospitals, internal referrals or the Huron-Perth Legal Clinic. The incumbent will perform other duties as required, which may include, but are not limited to, data entry, report generation and community education. Also, the incumbent will be required to work flexible working hours as required (See “Working Hours”).

The role involves high levels of collaboration with hospitals, legal clinics, landlords, and community service providers to address complex financial, mental health, medical, and social barriers to housing stability.

This position operates within a recovery-oriented, trauma-informed, and harm reduction framework.

POSITION RESPONSIBILITIES:

1. Intensive Case Management

Conduct comprehensive bio-psychosocial assessments.

Develop individualized housing stability and service plans

Provide regular in-home and community-based visits

Deliver intensive support during high-risk transition periods (first 3–6 months of housing)

Monitor early warning signs of housing instability

Provide crisis intervention as required

Maintain a manageable caseload to ensure intensity of service (approximately 15–20 clients)

2. Housing Stabilization & Eviction Prevention

Support clients in understanding lease agreements and tenant rights

Work collaboratively with the Huron County to assess eligibility for subsidy when available

Educate clients on landlord-tenant responsibilities

Intervene early in situations of rental arrears or lease violations

Develop repayment plans in collaboration with landlords.

Mediate landlord-tenant conflicts

Collaborate with legal clinic partners when eviction notices are issued

Support clients through Landlord and Tenant Board processes when necessary

3. Financial & Income Support Navigation

Assist with applications for income supports (OW, ODSP, CPP-D, etc.)

Support budgeting and financial literacy development

Connect clients to rent banks and emergency financial supports

Assist with access to discretionary benefits

Support identification replacement and banking setup

Facilitate referrals to trusteeship services if appropriate

4. Mental Health & Health System Coordination

Facilitate referrals to community mental health and addiction services

Coordinate care with primary care providers

Collaborate with hospital discharge planners to ensure safe transitions into housing

Support access to home care and community health services

Accompany clients to appointments when appropriate

5. Apartment Location & Housing Search Support

Accept referrals for housing search assistance

Support clients in locating appropriate rental units

Assist with rental applications and documentation

Liaise with landlords to secure units within subsidy parameters

Ensure stabilization supports are in place prior to move-in

6. Community & Systems Collaboration

Participate in case conferences and coordinated access meetings

Maintain active partnerships with:

County housing services

Hospitals and discharge planners

Legal clinics

Mental health providers

Income support offices

Advocate for clients within systems that present barriers to housing stability

7. Documentation & Reporting

Maintain accurate and timely case notes

Track housing retention outcomes and service indicators

Complete required reporting for funders and internal evaluation

Ensure confidentiality and compliance with privacy legislation

QUALIFICATIONS and SKILLS:          

Degree or diploma in health or social services; registration with a professional college preferred

Minimum of three (3) years’ work experience in a social service field

Knowledge of Service Prioritization Decision Assistance Tool (“SPDAT”) and other standardized assessments is an asset

Strong and demonstrated understanding of the issues and challenges faced by individuals experiencing homelessness, including mental illness, addictions legal and justice issues, victimization, and abuse

Ability to work independently and within a multi-disciplinary team

Strong and demonstrated understanding of “Housing First” principles

Knowledge of community resources and services available in Huron County and surrounding areas

Ability and willingness to promote harm reduction practices and anti-oppression practice

Excellent interpersonal, communication and counselling skills

Strong ability to assess, advocate and problem solve in conflict and/or crisis situations

Experience working with individuals from diverse backgrounds

Excellent analytical, organizational and time management skills

Demonstrated computer literacy

CPR and First Aid Certified

Crisis prevention and de-escalation training is an asset

Vulnerable Sector Screening – police check

Valid Driver’s license, reliable vehicle, and automobile endorsement insurance. Ability to travel throughout Huron County

Working Hours: Employees will be required to work Monday to Friday 9am to 5pm with flexibility, when required, and with notice, to support participant needs – 70 hours in a bi-weekly period.

This position has On-Call responsibilities, on a rotational basis, with each member of staff expected to be On-Call is compensated at $150 per seven (7) days On-Call, prorated if the staff member works more or fewer than seven (7) days.