Supportive Services Coordinator

Major Functions:

• Provides general case management (including intake) and referral services to all residents needing such assistance. Formal case management (i.e., evaluation of health, psychological and social needs, development of an individually tailored case plan for services and periodic reassessment of resident’s situation and needs) for a resident is needed when such service is not available through the general community
• Help to coordinate the provision of supportive services to help all residents continue to age in place and delay or avoid the need for higher levels care
• Routinely assess service needs in response to changing circumstance, i.e., Consulting with residents returning from the hospital/rehabilitation to determine need for additional support
• Conduct assessments for all residents participating in the program at a minimum of annually, complete a health and wellness assessment that gathers information about the residents’ physical, mental, functional and social status.
• Develop an individual health aging plan/service plan to address identified interests and needs. Plans are guided by information from the individual assessments, summary reports of aggregated need pull from the data base system, and personal observations
• Establishes links with agencies and service providers in the community; shops around to determine/develop the “best deals” in individualized, flexible, and creative services for the involved resident(s)
• Refers and links the residents to service providers in the general community, including, but not limited to, case management, personal assistance, homemaker, home delivered meals, transportation, counseling, occasional visiting nurse, preventive health screening/wellness, and legal advocacy
• Monitors the delivery of services to residents to ensure they are appropriate, timely and satisfactory
• Establishes partnerships with other public and private agencies, state social service agencies, hospitals health systems and primary health providers
• Organize and coordinate onsite wellness and health improvement programs, events, and activities
• Engage and motivate residents, including socially isolated individuals, to enroll in the program and be active participants in improving/maintaining their health and wellbeing
• Assembles a directory of community services and providers and makes it available to residents, families, and management
• Meets with service providers as needed and appropriate
• Reports all suspected abuse situations to the appropriate agency
• Educates residents on service availability, application procedures, client rights, etc. providing advocacy as appropriate
• May set up volunteer support programs with service organizations in the community
• Helps the residents build informal support networks with other residents, family and friends.
• May provide assistance to resident’s councils but only at the request of the council.
• Educate other staff on the management team on issues related to aging in place and service coordination, to help them to better work with and assist the residents
• Establish and maintain communication channels with the property management staff to appropriately share information concerning residents and work together to address the residents needs
• Maintain all necessary resident and program data in the AASC Online data accurately, such as personcentered interview and health and wellness assessments, interactions with residents, resident participation in programs and unanticipated events (e.g., falls, emergency department visits, planned and unexpected hospitalizations, etc.)
• Use the residents’ data to monitor and improve program practices and operations
• Maintain resident information accordance with applicable privacy and confidentiality requirements
• Ensures that the cost of service providers does not exceed the resident’s ability to pay or place undue financial burden on the resident
• Ensure that all residents have access to a Primary Care Provider and are enrolled in their patient portals

Administrative Responsibilities:

• Documents contact with residents, providers, and families
• Maintains individual files on residents
• Completes reports, with copies given to the supervisor, quality assurance administrator, and the property manager in an accurate and timely manner
• Pursues avenues for additional services through private, local, state, and federal sources
• Participate in all trainings required by National Services staff
• Engage in the quality assurance process
• Participate in interviews, surveys or other evaluation activities
• Keep all old residents’ files in a secured and locked area and/or computer to insure confidentiality as most files are scanned in the AASC System

Qualifications:

• Bachelor’s Degree with a concentration in Social Work, Gerontology, Psychology, Sociology, Counseling, Public Health, or Therapeutic Recreation is preferred OR equivalent experience in case management
• Demonstrated working knowledge of services available in the community, with particular knowledge of services that are provided for the population living in the facility
• Basic computer proficiency, including ability to maintain data in an electronic databased, communicate via, email, use the internet, and operate word processing software to create program materials
• Training in the aging process, elder services, disabled services, drug and alcohol abuse and mental health issues
• Awareness of eligibility for and procedures of federal and state entitlement programs
• Good communication, writing, problem solving, and organizational skills
• At least two years of experience conducting supportive service needs assessments and using such assessments to identify and locate specific services that address individual residents’ needs.
• Knowledge of the eligibility requirements for applicable federal and state entitlement programs
• Knowledge of the process of referring individuals to the services that they require, as well as the ability to build relationships with said service providers and provider agencies.
• Experience building relationships with local service providers, community institutions, and local government agencies
• Demonstrated ability to advocate, organize, problem‐solve, and achieve results for older adults and people with disabilities.
• Knowledge of lifecycle issues of older adults and families, as well as the physical and mental impairments common to the aging process
• Experience working with older adults in a direct service capacity
• Ability to establish trust, listen, and assist residents in defining their problems, while identifying possible solutions and resources and helping residents decide the best course of action
• Ability to selfdirect and work independently, but also function will as part of a team
• Cultural competency in working with individuals from different ethnic and racial backgrounds, including working with nonEnglish speaking adults
• Good communication, writing, problem solving and organization skills in addition to strong advocacy capabilities

Note: The service coordinator is NOT to provide support services directly or assist with other administrative work normally associated with managing the property. Additionally, the service coordinator is NOT an activities director.

About Volunteers of America of Pennsylvania

Volunteers of America of Pennsylvania’s (VOAPA) ministry of service is to empower vulnerable communities, families, and individuals through support and resources that lead to health and stability. We use evidence-based, data-driven information to develop community-based, contextualized, holistic, and empowering interventions. Our core values are: Person-Centered; Empowering; Community-Based; Responsive. VOAPA has regional offices located in Northeast, Lehigh Valley, Central, and Southwest Pennsylvania Communities.