What are the responsibilities and job description for the Support Coordinator RN position at Detroit Area Agency on Aging?
Conducts face-face assessments/reassessments from a clinical perspective on designated assigned cases.
· Obtain medical history and document pertinent clinical information from participants related to their medical diagnoses and assessment findings
· Utilizing assessment, develops a plan of care directed by the client (Person Centered Care Planning)
· Monitor participants for conditional changes associated with their physical and mental health well-being
· Preforms monthly medication reconciliations
· Develops and completes care plans and other required documents. Reviews and modifies care plans as directed by the client / caregiver during the reassessment and obtains the clients signature of approval.
· Maintains regular, ongoing contact with clients, caregivers, physicians and service providers listed on service plan through home visits and phone calls.
· Educates clients, caregiver and service providers regarding the roles and responsibilities of each party, assuring that services are provided as documented in the care plan.
· Conducts Nursing Facility Level of Care assessment as required.
· Continues to evaluate the appropriateness of the service plan, adjusting it as needed.
· Monitors client progress in relation to goals and objectives listed in the care plan.
· Interfaces with community resources as needed to support client.
· Collaborates with peers (RN or SW) in coordinating services.
· Produces timely and accurate commuter entry reports.
· Maintains client confidentiality
· Participates in training, supervisory meetings, in-services and continuing education opportunities.
· Abides by DAAA’s and Waiver Codes of Ethics.
· Participates in other duties as assigned.
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