Enhanced Service Coordinator
The Enhanced Service Coordinator (ESC)is a three-year, grant-fundedposition under the US Department of Housing &Urban Development's Supportive Services Demonstration (SSD).Any funding for the continuation of the ESC position, including any augmentation, is subject to the availability of funds after the demonstration ends. The ESC assistsresidents with identifying and addressing their social serviceand health needs to help optimize health andwell-being. The ESC serves as the primary manager of the HUD supportive servicesdemonstration and the central pointof communication and coordination.Employing a person-centered approach, the ESC works in concertwith each residentand their family members, ifappropriate; the Wellness Nurse (WN); and community health and social servicespartners to help residents address their needs, achieve their goals, andsupport their ability to safely age in place. The ESC also acts as the primaryliaison between the housing property and the SSD Implementation and Evaluation Teams. Reports to: Senior/Community ManagerSupervises: N /ACompensation: Non-exempt / hourlySummary: Assists residents with identifying and addressing their social service and health needs to help optimize health and well-being. The ESC serves as the primary manager of the HUD supportive services demonstration and the central point of communication and coordination. Essential Duties and Responsibilities: * Serve as the central coordinator and communicator for the supportive services demonstration within the housing community.* Serve as a liaison to the external community, helping to educate community organizations about the supportive services program, and develop partnerships.* Establish and execute outreach processes, along with the WN and property management staff, to educate residents about and facilitate enrollment in the supportive services demonstration.* Enroll residents in the supportive services demonstration, including explaining all privacy and confidentiality protections.* Oversee an initial and on-going resident assessment process, including conducting person- centered interviews to understand resident lifestyles and interests, and collaborating with the WN to complete a resident health and wellness assessment that gathers information about resident physical, mental, functional, and social status.* Develop individual-level and community-wide healthy aging plans, with input from the WN and resident, to address identified interests and needs. Plans are guided by information from the individual assessments, summary reports of aggregate needs pulled from the data platform, personal observations, and input from partners.* Organize and coordinate on-site wellness and health improvement programs, events, and activities.* Oversee ongoing implementation of the individual and community healthy aging plans, with the ESC and WN each fulfilling specific roles.* Engage and motivate residents, including socially isolated individuals, to enroll in the program and be active participants in improving/maintaining their health and well-being.* In collaboration with the WN, review discharge plans to help ensure timely follow-up of needed supports and coordination of care for residents discharged from the emergency department, hospital, skilled nursing facility, or home health care.* Assist residents to ensure the ongoing delivery and receipt of services and periodically assess residents for new assistance and care needs in response to changing circumstances.* Assist residents in identifying and accessing needed services and benefits, and serve as a liaison or advocate for residents when help is needed to secure resources.* Establish informal and formal partnerships with health and supportive service agencies in the community to ensure that the necessary services are available and delivered in a collaborative and efficient manner.* Establish and maintain communication channels with the WN, community partners and property management staff to appropriately share information concerning residents and identify ways in which resident needs can be efficiently addressed.* Convene and facilitate team meetings that may occur with the WN and/or community partners to triage resident needs and develop strategies to efficiently address and coordinate service needs.* Produce program materials, such as a periodic resident newsletter.* Maintain all necessary resident and program data in the electronic data platform, including information from the person-centered interview and health and wellness assessment, interactions with residents, resident participation in programs, and sentinel resident events (eg falls, ED visits, etc.).* Maintain and share all personal resident information in accordance with applicable privacy and confidentiality requirements.* Collaborate with the SSD Implementation and Evaluation Teams, including participating in all trainings, to the greatest extent possible; engage in peer-to-peer learning activities; engage in a quality assurance process; and participate in interviews, surveys, or other evaluation activities.QUALIFICATIONSTo perform this job successfully, an individual must be able to perform each essential duty well. The requirements listed below are representative of the knowledge, skills and abilities required. Associates must follow requirements for training/development plans. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of the job. Education: A Bachelor of Social Work or degree in gerontology, psychology or counseling. Other college degrees and/or work experience may be substituted, as appropriate.Skills: The position requires, but is not limited to, the following:* Knowledge of supportive services and other resources available in local area served to help assist low-income older adult.* Ability to translate medical jargon into easily understandable language and to communicate at appropriate literacy and cognitive levels.* Strong verbal, written, and interpersonal communication skills.* Familiarity and understanding of working with individuals with mental health needs.* Cultural competency in working with diverse populations and individuals from different ethnic and racial backgrounds, including working with non-English speaking adults.* Experience conducting comprehensive needs assessments and developing/implementing plans to help address identified needs.* Experience building relationships and partnerships with local service providers, community institutions, and government agencies.* Experience using motivational interviewing, active listening, and person-centered care concepts to help encourage individuals to engage in addressing and managing their own care needs.* Understanding of affordable housing operations and fair housing practices.* Understanding of using data to monitor and improve program practices and operations. Experience and enthusiasm for working with older adults.* Bi- or multi-lingual in Russian.Physical Demands:* Must be capable of physically accessing all exterior and interior parts of the property and amenities.* Must be able to push, pull, lift, carry or maneuver weights of up to 20lbs. independently and 50 lbs. with assistance.Computer skills: * Basic knowledge of computers * Ability to use Outlook * Intermediate to advanced knowledge of MS Word and Excel, Realpage/OneSite* Ability to develop advanced knowledge of other programs or systems as needed* Basic Internet knowledge Learning & Development:Maintain a commitment to ongoing personal development and career growth through career path activities provided through the corporate office and external sources as needed.