Job Description and Responsibilities

Under the direction of the Director of Assisted Living and Care Management and in collaboration with the Chief Operating Officer, incumbent is responsible for the development and provision of a comprehensive social services program for the residents of Assisted Living and Duncaster. The incumbent is to ensure that the Duncaster Social Worker and Transition Coordinator focuses on the goal of providing a healthy psycho-social environment in which residents and staff live and work. Responsibilities will include case management, social worker assessments, discharge planning, coordinating and providing support for transitions of levels of care, therapeutic counseling, and acting as a liaison for family members. Performs all job responsibilities according to Duncaster’s Policies and Procedures.

Duties and Responsibilities

The following description of job responsibilities and standards are intended to reflect the major responsibilities and duties of the job, but is not intended to describe minor duties or other responsibilities as may be assigned from time to time. Contributes to the achievement of excellence through the quality and care values of the mission of Duncaster.

Transitions Navigator:

• Coach, educate and support residents and families to assume a more active role in their care while enhancing communication between resident and primary care provider that results in improved health outcomes and fewer acute care admissions.
• Manages the Duncaster Transitions program to assure person centered appropriate level of care, and choice while working towards increased census.
• Identify the skilled and psychosocial needs of the resident to match them up with the appropriate services to most effectively manage and maintain the client in their current environment.
• Educates and informs residents, families and home care agencies of the Duncaster Policies and Procedures.
• Provides leadership and education to staff and family regarding the emotional/psychosocial needs of residents and families at Duncaster.
• Shares and discusses transitions and move in-move outs at the weekly Reno meeting.
• Evaluates all potential assisted living residents to help determine if they meet the level of care along with Assisted Living Director.
• Works with Marketing, Finance, Facilities, and Resident Services to assure a smooth transition within Duncaster including Dogwood.
• Identify potential residents for level of care change and work with resident, family, physician and other stakeholders by providing education and support for this change.
• Assist residents with activating long term care insurance, reviewing qualifications and helping find a payor source for additional services to help resident age in place.

Social Services:

• Develop and maintain collaborative relationships with community resources, referral sources, social work professional organizations and educational groups in order to assure effective and safe transitions.
• Is an active and driving member of the interdisciplinary teams with responsibility for successful transition back to the community through effective resident/patient care planning.
• Works cooperatively and supportively with all Duncaster departments, particularly the Geriatric Hartford Healthcare Medical Group.
• Maintain articulate documentation in a timely manner in accordance with OBRA and Connecticut ALSA regulations.
• To serve as the ALSA Service Coordinator to:
  • Ensure that services are provided or made available to all residents.
  • To assist residents in making arrangements to meet their needs.
  • To establish collaborative relations with provider agencies.
  • To establish a resident council – compile minutes and respond to requests from meetings in social assisted living and Dogwood.
  • To serve as on-going liaison with ALSA QA committee.
• Fulfill the service coordinator responsibilities set forth in DPH ALSA regulations.
• Advocate for residents to resolve crises.
• Collaborate with other professionals to evaluate patients’ medical or physical condition and to assess resident needs.
• Counsel, educate and coach residents in individual and group sessions to help them manage their disease, overcome dependencies, or recover from illness to reduce or avoid hospital readmission.
• Utilize consultation data and social work experience to plan and coordinate resident care, following through to ensure service efficiency.
• Plan discharge from one level of care to another as appropriate, including home as applicable.
• Organize support groups or counsel family members to assist them in understanding, dealing with and supporting the resident.
• Modify treatment plans in conjunction with primary care physician, to comply with changes in residents’ status.
• Monitor, evaluate and record resident progress according to measurable goals described in treatment and care plan.
• Identify environmental impediments to resident progress through interviews and review of resident records and work to remove impediments.
• Assist residents with Medicare part D enrollment.
• Assist residents with secondary insurance reviewing to assure the resident is meeting their Duncaster agreement, assist resident to find proper insurance and help contact residents' pension to clarify if there are options that meet Duncaster agreement.
• Assist residents with advanced directives.
• Review and support end of life care decisions with residents.
• Assist with arranging programing for dementia education and end of life education for Duncaster.
• Keep paperwork for private duty aides current.
• Along with Assisted Living Director, facilitate neighborhood forums.

Education and Experience

• Working knowledge of OBRA regulations; JCAHO standards; community resources; social service program development and review; social process, human behavior and interpersonal relations.
• Bachelor’s degree in social work is required.
• Minimum of 1 year of experience with the geriatric population is required.
• Excellent communication skills and teamwork are essential.

Environment & Working Conditions

• Must be able to move intermittently throughout the workday.
• Must be able to speak and write the English language in an understandable manner.
• Must possess sight/hearing senses or use prosthetics that will enable these senses to function adequately so that the requirements of this position can be fully met.
• Must function independently, have personal integrity, have flexibility, and the ability to work effectively with other personnel, residents and support agencies.
• Must be in good general health and demonstrate emotional stability.
• Must be able to relate to, and work with, ill, disabled, elderly, emotionally upset and at times, hostile people within the facility.
• Must be able to assist in the evacuation of residents.

What are the benefits?

• 401(k)
• 401(k) matching
• Dental insurance
• Disability insurance
• Employee assistance program
• Flexible spending account
• Health insurance
• Life Insurance
• Paid sick time
• Paid time off
• Tuition reimbursement
• Vision insurance
• Free Access to Aquatic & Fitness Center
• Employee discount lunches

Req. 1827

Job Snapshot