Job Description

Job Description:

Position Summary

HSL provides enhanced housing with services to seniors living in its three affordable housing locations, and at partner housing sites, with the goal of improving quality of life and supporting independent living. For this role you will work at Riverside Towers. At its core, enhanced housing with services is a proactive approach wherein resident services staff regularly and actively reach out to each individual resident to engage with them around their health and wellness, identify areas of need/risk and provide intensive, individualized case management and support as needed and desired by the resident.

The ideal candidate for this role is a social worker or case manager with experience in senior services, mental health services, or healthcare navigation.

The Wellness Coordinator (WC) serves a lead role in the R3 Initiative engaging residents in wellness assessments and health education programs, connecting residents to needed services, providing a wide variety of case management tasks, coordinating activities with the Nurse Care Manager, and ensuring that all interventions are documented and tracked.

The Wellness Coordinator is directly responsible for assuring that there is excellent communication and coordination with all partners, including emergency responders, payers and local providers to support residents in living independently and safely for as long as possible.

Core Competencies

• Commit to the organization’s core values of respect, dignity and empowerment.

• Able to form trusting relationships with residents, families, and team members.

• Work collaboratively with colleagues, both within and outside the HSL continuum.

• Listen attentively; speak respectfully; maintain confidentiality.
• Provide the highest quality of preparation and presentation.
• Have a “can-do” service mentality.
• Accept responsibility for all tasks assigned.
• Work independently toward achieving program goals

Position Responsibilities

• Conduct wellness assessments of residents to determine needs and goals; develop wellness plans addressing physical, social, cognitive, spiritual and mental health domains.
• Coordinate with primary care physicians, mental health providers and hospitals.
• Partner with housing staff to tailor programming that meets resident needs.
• Educate housing staff members including office, maintenance, housekeeping, programming. and dietary staff to identify and communicate concerning changes in residents’ condition.
• Coordinate with residents to complete files including important health care information, end of life planning, and emergency contacts.
• Support on site services and connection to required off site services by following up with at risk residents to ensure adherence to health and wellness related activities.
• Develop relationships with all payers serving seniors in the sites.
• Implement effective communication systems between housing and providers to relay important information (changes in condition, transitions between settings, changes in behavior/activity).
• Promote self-care among residents through individualized coaching to identify personal goals and implement programs and services that support those goals as well as coordinate with care providers.
• Partner with and make referrals to all appropriate local service providers, for example: Visiting Nurses Associations, ASAP’s, Rehabilitation Services, PACE Programs, Adult Day Health Programs, Memory Evaluation Programs, etc.
• Participate and/or lead care planning meetings at the housing site.
• Assess the needs of residents with dementia and make appropriate referrals as needed.
• Work with the Nurse Care Manager to plan, schedule and implement Evidenced Based Programs.
• Work with local hospitals, HSL Home Care and/or VNA case management to ensure safe discharges with appropriate service coordination.
• Assist residents with transition to other levels of care as needed; conduct family meetings and attend off-site team meetings when necessary to coordinate care and discharge planning needs.
• Offer advocacy for residents and serve as a liaison for families.
• Coordinate and participate in the tracking of metrics/measures as well as the creation of reports on outcomes.

Qualifications 

• Masters degree in social work or a human service field and 1-2 years of experience working as a case manager or care coordinator in aging services strongly preferred;
• Bachelors degree with 3-5 years experience required.
• Must have compassion for and a desire to work with a senior population.
• Excellent organization and interpersonal skills, including the ability to manage multiple projects simultaneously, work efficiently and proactively as part of a team.
• Must be a professional, proactive, collaborative, conscientious, and results-oriented individual. 
• Must have an optimistic and positive demeanor, excellent oral and written communication skills, good intuition and sound judgment.
• Must be motivated to learn and flexible to change.
• Must be able to collect needed information and document clearly in AASC Online software.
• Computer literacy; experience with Windows, Word, Power Point, and Excel
• Some travel in the Boston metro area for site visits and meetings is required.
• Certification in Dementia Care preferred.

Physical Requirements

• Must be able to lift, push and pull 25 pounds.
• Must be able to stand, walk, drive and sit during scheduled work times.

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