Resident Services Coordinator

Overview

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 Resident Services Coordinator (RSC) serves a lead role in the building, engaging residents in wellness assessments and health education programs, connecting residents to needed services, providing a wide variety of case management tasks and ensuring that all interventions are documented and tracked in a timely manner.

Case management tasks are coordinated and supported by the Nurse Care Manager, and resident programs are shared with the Programming Coordinator. The RSC is directly responsible for ensuring excellent communication and coordination with all partners, including BHA staff, emergency responders, payers and local providers to support residents in living independently and safely for as long as possible.

• Energetic, passionate, resourceful, strong presence that will represent HSL
• Have a “can-do” service mentality.
• Committed to active outreach to residents, including engaging with them in their apartments, during programs, emergencies, etc. Being ‘out and about’, visible and connected.
• 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.
• Accept responsibility for all tasks assigned.
• Work independently toward achieving program goals

• 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.

• Bachelors degree with 3-5 years experience required.
• 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;
• Must have compassion for and a desire to work…