Elders' Program Coordinator

Description

The Elder Care Program Coordinator supports Tribal Elders through frequent home visits, welfare checks, needs assessments, and connection to medical, social, community, and Tribal resources. The position builds trusting relationships with Elders, identifies changes or unmet needs, assesses safety and daily living needs, coordinates services and care plans, and works with Elders, families, caregivers, healthcare providers, and service providers to support the Elder’s well-being and independence.

The position also maintains accurate documentation and case records and follows through to ensure identified needs, referrals, and services are addressed.

• Conduct home visits and welfare checks with Tribal Elders to assess and monitor their physical, social, emotional, cultural, and environmental well-being; identify changes in condition, safety concerns, isolation, unmet needs, or barriers to independent living; and determine appropriate follow-up, resources, referrals, or support services.
• Evaluate the effectiveness of the care plans and recommend adjustments as needed.
• Maintain outreach and provide support services to Tribal Elders based on individual needs.
• Conduct Activity of Daily Living Assessments to Determine eligibility for program services.
• Connect Tribal Elders with essential community resources, providing hands‑on, in‑person assistance as needed.
• Prepare and submit payment requests and Elder In-Home Care Timesheets for supervisor review and approval.
• Assist Tribal Elders with navigating resources such as Washington Connections, Apple Health and DSHS Long-Term Services and Supports; while collaborating with medical professionals and other service providers to support coordinated care.
• Coordinate transportation for health-related appointments as needed.
• Maintain transportation logs, reports, and related program documentation.
• Prepare purchase requests for program services, supplies, and activities for program manager review and approval.
• Participate in Elder program activities and events in a respectful and supportive manner.
• Maintain accurate client records, case notes, and other required program documentation.
• Participate in department meetings and trainings as appropriate.
• Assist Tribal Elders’ physical and mental wellness, needs, preferences, and abilities to develop individualized care plans.
• Coordinate services and care plans for Tribal Elders by working with Elders, families, caregivers, healthcare providers, Tribal programs, and state or community resources; assist with identifying appropriate services and resources; and follow up to ensure identified needs, referrals, and care coordination plans are addressed.
• Document Trial Elders’ progress, including charting referrals, home visits, and other notable interactions
• Evaluating Tribal Elders’ progress periodically and make adjustments to care plans or services as needed to improve outcomes.

• Assist with program policy development as needed.
• Utilize Tribal Assister certification to assist Elders with enrollment in Apple Health and other eligible assistance programs.

• Assist in identifying Tribal Elder needs to ensure optimal support and care.
• Participate in program staff meetings, provider meetings, and work groups as needed.
• Attend required trainings and continuing education necessary to effectively perform job duties.
• Assist with Title VI Elder Needs Assessment Survey and other surveys for information.
• The Tribe values its commitment to community service and the well-being of its members. In recognition of this, each employee may be expected to perform duties from time to time which may not be related to their regular responsibilities.
• Other duties as assigned.

• Proficient in…