Care Coordinator

Make a difference in the lives of adults with disabilities and older persons by providing advocacy for them to remain in the setting of their choice!

The Area Agency on Aging & Disabilities of SW WA is part of the national network of Area Agencies on Aging, a public service agency dedicated to helping persons aged 60 and over, adults with disabilities and their families to access needed community services in Clark, Cowlitz, Wahkiakum, Klickitat, and Skamania Counties.

• FLSA: Non-Exempt
• Reports to: Care Coordinator Supervisor
• Supervisory Responsibilities: None
• Pay Grade: 20B

Provides support for designated clients/beneficiaries which includes coordinating an array of services designed to improve the health of high needs, high risk clients/beneficiaries. Care coordination responsibilities will include assessment, care planning and monitoring of client status, and implementation and coordination of services. Provides support to clients/beneficiaries for effective care transitions, improved self‑management skills and enhanced client/beneficiary‑provider communication. Will facilitate interdisciplinary consultation, collaboration, and care continuity across care settings.

• Engages clients in care coordination activities designed to promote improved utilization of health care services, including the creation and ongoing maintenance of a patient‑centered, goal‑oriented Health Action Plan (HAP).
• Assesses activation level for self‑care through use of the Patient Activation Measure® (PAM®).
• Provides evidence‑based health assessments and screenings such as BMI, PHQ‑9, Katz ADL, GAD‑7.
• Provides transition support services, generally based on the Coleman model of Care Transition Intervention.
• Works with supervisors and other healthcare providers, hospital discharge planners, skilled nursing facility staff, and staff at the client’s health home to implement services and analyze the disposition of cases.
• Coaches the client/beneficiary to build confidence and competence in four conceptual areas, or "pillars": medication self‑management, use of a patient‑centered health record, primary care and specialist follow‑up, and knowledge of red flags of their condition and how to respond.
• Performs facility visits, home visits, and follow‑up telephone calls to develop critical coaching relationships, to empower clients/beneficiaries to take an active and informed role in their discharge planning and introduce them to the patient‑centered Personal Health Record.
• Tracks coaching‑related metrics and reports on intervention progress.
• Coordinates follow‑up activities and referrals with other programs including the Family Caregiver Support Program and AAADSW/HCS Medicaid Case Management.
• Coordinates and communicates regarding the client/beneficiary's post‑discharge status with all involved health care providers including, but not limited to primary care, mental health, specialty care, and pharmacy.
• Identifies and addresses barriers to overcome impediments to accessing health care and social services.
• Provides referrals and advocacy for clients/beneficiaries and their caregivers to community long‑term services and supports, which includes family caregiver programs, nutrition programs, in‑home care, and case management.
• Provides teaching about self‑management of the client/beneficiary's chronic health condition and provides resource links to ongoing chronic disease self‑management support services.
• Develops and maintains complete and concise client/beneficiary files in compliance with policy to appropriately document activities performed for the client/beneficiary and all elements required for specific programs.
• Maintains all required documentation related to services provided and conforms to monthly deadlines.
• Participates in staff meetings, public education, and provider training sessions, as appropriate.
• Develops and maintains relationships with community agencies and organizations that have the potential to provide resource support to the program or individuals.
• Prepares correspondence, memos, and client related written materials, as appropriate.
• Participates in continuing education and training programs.
• Works…