Case Manager – ACTT Step Down Program

About the Job:

Reporting to the Assertive Community Treatment Team (ACTT) Nurse Practitioner, the ACTT Step Down Case Manager supports individuals living in the community with complex serious mental illness who are ready to transition from ACTT to less intensive and ongoing services. The position provides individualized case management, transition and discharge support through the ACTT Step Down Program, a collaborative initiative designed to support safe, coordinated and effective transitions to William Osler Health System (WOHS), primary care, psychiatry, community mental health and addiction services, case management and other appropriate community-based supports.

The position works collaboratively with clients, families/caregivers, ACTT staff and external partners to develop and implement individualized transition plans, coordinate referrals and address barriers to successful discharge to ensure clients are connected to the most appropriate ongoing services and supports based on their clinical and functional needs.

Duties and Responsibilities:

• Provide individualized case management and recovery-oriented support to clients transitioning from ACTT to less intensive and ongoing services.
• Develop and implement individualized transition and discharge plans in collaboration with clients, families/caregivers and the care team.
• Coordinate and facilitate transitions to appropriate discharge destinations, including WOHS outpatient services, primary care, psychiatry, community mental health, addiction services and other community supports.
• Establish and maintain consistent clinical collaboration between community and hospital settings to support seamless communication, continuity of care and successful client transitions.
• Work closely with the ACTT Step Down Nurse Practitioner, ACT Teams and external providers to coordinate care and address barriers to transition.
• Support clients in developing and maintaining community supports, daily living skills and social skills necessary to promote independence and successful functioning in the community.
• Complete appropriate clinical assessments and standardized screening tools, including C-SSRS and OCAN, as required.
• Identify risk factors and support crisis planning, safety planning, relapse prevention and harm reduction to promote stability in the community.
• Provide psychoeducation, supportive counselling and skills development to clients and families/caregivers, and advocate for access to appropriate services.
• Maintain accurate clinical documentation, records and statistical information in accordance with SHIP standards, while promoting client-centred care, equity, diversity and inclusion and adhering to SHIP’s Health & Safety and Client Safety frameworks.

Qualifications:

• Post-secondary education in Social Work, Social Services, Health Services, or equivalent.
• 2+ years’ experience supporting individuals with mental health challenges in the community.
• Knowledge of psychiatric symptomology, and suicide assessment/intervention.
• Demonstrated knowledge in psychosocial assessments, mental illness, counselling, crisis management and harm reduction.
• Experience supporting clients through care transitions, including discharge planning and community integration.
• Knowledge of the Assertive Community Treatment Model of Care, the Mental Health ACT, housing, social, financial, vocational, and other community resources

Reporting Function:

The ACTT Step Down Case Manager reports directly to the ACTT Nurse Practitioner and works closely with the ACT Teams. They interact with internal and external stakeholders at all levels, serving as a support and advocate for clients, families, and the team.

This position has no supervisory responsibilities.

Working Conditions and Physical Requirements:

• Shift will be typically 19 hours per week flexible between Wednesday - Friday
• Contract until September 15, 2027
• Able to work well with internal and external clients
• Able to drive, walk (site locations) regularly
• Able to sit for prolonged periods of time
• Able to answer and communicate telephone calls and general computer use
• Computer screen use (multiple screens if applicable) for prolonged periods of time
• Able to lift up to 20lbs (product, documents, etc.)
• Travel by vehicle to community sites for client support as required

Ship Values:

• Compassion, Hope, Inclusive, Respect, Professional

About Us

Services and Housing In the Province (SHIP) is a Provincial leader in the broader public sector that builds strategic partnerships and programs that support the fundamental rights for Housing and Health Services throughout the Peel Region, Dufferin County, Region of Waterloo and surrounding areas.

Our commitment to increase quality of life through health services and housing supports that promote mental and physical health and wellness is at the forefront of every employee we hire. We value compassion, hope, inclusiveness, respect, and professionalism.

Our organization has supported the region for over 35 years and employs over 550 passionately engaged employees ranging from office administration, nurses, and service health specialists to housing specialists all dedicated to the community, clients, and families.

Accessibility

“SHIP strives to be equitable and inclusive in all that we do. Equity is a core value, and we are committed to providing an inclusive selection process. We encourage applicants from equity deserving communities including women, Black, Indigenous, other racialized groups, 2SLGBTQ+ persons, individuals with disabilities and others who will contribute to and enrich the organization and its values. We are committed to inclusive, barrier-free recruitment, selection processes, and work environments. Please advise the People and Culture Department of any accommodations needed in accordance with the Accessibility for Ontarians with Disabilities Act, 2005 and the Ontario Human Rights Code to ensure you have access to a fair and equitable process”.

Application Instructions

Interested candidates are encouraged to apply before November 19, 2026

Why Work For Us?

Work-Life Balance

SHIP believes a healthy work-life balance is essential for both professional success and personal well-being. We strive to create a company culture that values and supports the well-being of our employees, while also pushing innovation in our organization

Our Vision
Quality Housing, Quality Services, Quality Lives

Our Mission
To increase quality of life through health services and housing supports that promote mental and physical health and wellness

Our Culture
Leader and innovative partner in the community. Our programs welcome employees into our caring, compassionate, and innovative culture. We listen; we know what it means, and why it matters.

Our Commitment
People are at the forefront of our success. Below are just a few ways our full-time permanent staff have personal and professional success:

• Competitive Salaries with Annual Performance Reviews
• Comprehensive Health Plans
• Group RRSP (5% Employer Contributions)
• 12 Paid Health, Wellness, and Sick Days
• 10 Paid Vacation Days
• 3 Paid Personal/Floating Holidays
• Generous Parental and Family Leave
• Learning and Development Opportunities
• Travel Allowances
• Employee Assistance Program
• Company Culture to be Proud of
• Possibility to Create a Real Impact

35+

Years focused on Clients, Tenants, Staff, and Families

5,000+

Clients and Residents served annually

20+

Programs and Service offerings in Southern Ontario

500+

Dedicated, Respectful, Compassionate and Professional Employees

Flexible schedule, Wednesday - Friday | 8:30am - 4:30pm
Union | 19 hours per week