Nursing Home Transition Coordinator - CLO

NURSING HOME TRANSITION COORDINATOR – CLO

 

DEFINITION:  Reporting to the PCA Nursing Home Transition Program Manager, the Transition Coordinator for the Nursing Home Transition Program will be responsible for coordinating all transition services available through the project, including initial counseling, assessment, service planning, training, monitoring, and post-transition advocacy and care management. 

 

QUALIFICATIONS:

Education:

§  BA/BS/BSW or MA/MS/MSW

 Experience:§  BA/BS/BSW candidates require three years social work or related experience.

 

Personal Characteristics: 

§ High energy level; able to manage a variety of tasks simultaneously.

§ Well developed interpersonal and communication skills.

§ Well organized.

§ High level of flexibility.

§ Possesses advocacy skills and a sense of professional ethics, such as consumer choice.

 

Additional Requirements:

§ Must have valid driver's license, a good driving record, and continuous access to a fully-insured car.

§ Pre-employment physical. 

§ Drug testing required.

§ Criminal history clearance.

§ Second language abilities preferred.

§ Knowledge of disability and aging issues, resources and service networks.

 

GOALS:

To successfully identify and transition long-term care facility residents and those at risk of placement into community based settings.  The transition coordinator maintains the highest level of professional ethics, continually seeking opportunities for growth and development.

 

DUTIES AND FUNCTIONS:

 

a. Works with community-based service agencies and long-term care facilities to identify potential candidates.

 

b.  Travels throughout service area to meet with individuals identified as appropriate for community living, as well as with family members, service providers, and others.

 

c. Interviews and discusses program with individuals who desire transition services.  Confirms eligibility, reviews both informal and formal supports, discusses options.

 

d.  Assesses individuals to determine appropriate referrals for service, including evaluation, documentation and follow up.  Reviews assessment with Project Manager and assessor.

 

e. Plans and coordinates relocation efforts with consumer, family, facility and community based service providers.

 

f. Plans and implements or coordinates community integration activities with consumer to increase independence, such as mobility and skills training and other community supports.

 

g.  Works with service providers to assure instruction desired or needed by consumer in areas such as financial management, household management, cooking, mobility, and decision-making.

 

h.  Monitors quality of service and consumer satisfaction to ensure successful transition.

 

i.  Provides necessary advocacy, support, guidance, and training to consumers living in the community. Recognizes supports, develops, and mobilizes informal and formal resources to meet consumers’ unmet needs, as well as focusing on consumers strengths.

 

j.  Works with consumer, his/her family and/or caregiver, to develop care plan, making use of supervision and consultation with other disciplines as necessary.

 

k.  Arranges for needed services and entitlements, working cooperatively with consumer, family members, and service providers.  Follows up on service delivered in specified amount of time, and works with consumer and provider(s) to assure appropriate match of service to specific need.

 

l.  Performs all care management functions for up to three months post transition.  Validates the assessment of the consumer’s needs in their environment.

 

m.  Attends and participates in meetings with long term care facilities and community based service staff.

 

n.  Completes all necessary documentation in a timely manner.

 

o. Solicits assistance from non-traditional services to facilitate persons transitioning, such as volunteers and in-kind contributions.

 

p.  Provides informational data as needed for reporting and accountability.

 

q. Participates in orientation and training, in-service training as assigned, and attends regular team and staff meetings.

 

r.  Transports consumer and his/her personal belongings in Transition Coordinator’s personal car for transition from long term care facility and transition preparation (i.e. shopping).

 

s. Other duties as assigned.

 

 

PERFORMANCE EXPECTATIONS:

§ Meets agency standards of care management practice.

 

§ Records and reports are legible, timely, accurate, complete, and relevant.

 

§ Ability to establish rapport with PCA staff, consumers, providers, and outside agencies.

 

§ Brings problems and possible resolutions to supervisory conference.

 

§ Assures quality services to consumers.

 

 

CUSTOMERS:

 

§ Residents of long-term care facilities

§ Caregivers of adults in need of long-term care services.

§ Service providers.