POSITION SUMMARY: Provide transitional care services to clients and their caregivers; follow the evidence-based protocols, assessments and timeframes accordingly, connect individuals to state, federal and community resources as appropriate. This position is hospital based.
Participates in departmental projects including Community Care Program (CCP), Managed Care Organizations (MCO), Caregiver Programs and other special projects.
Assess client needs including physical, social, health and environmental needs and how these interact by completing in-home assessments.
Targets services to those aged 60 and over, those who are isolated, in poor health, have income at poverty level, those over 75 years of age and those belonging to minority groups.
Connects individuals to available services and programs in their community which they may qualify.
Encourages and assists persons to gain access to needed services, including:
Making referrals and providing on-going follow ups to ensure services are in place.
Assist in completing all necessary forms for state and federal benefit programs
Advocate on behalf of client to gain access to benefit programs.
Maintains case notes and develops a person centered care plan for each client.
Advocates for clients in problem situations, including representing clients in appeals, and reconsiderations, and makes all attempts to meet client’s needs including through alternate resources.
Accepts case assignments as given with due consideration to case load, mileage and time guidelines.
Attends necessary training as provided by the Illinois Department on Aging.
Participates in case conferences, case planning and implementation, coordination of resources, ensuring alternate services and monitoring client’s progress.
Completes daily confidential charting for clients.
Participates in quality reviews.
Coordinates with other agencies as needed.
Cultivates community liaison relationships.
Expands the service resource network.
Serves as resource person for persons aged 60 and over and their families in the community.
Ensures the patient has scheduled doctor’s appointments, is prepared for the visit, and has appropriate transportation.
Completes medication reconciliation and connects with the interdisciplinary team as issues arise.
Ensures home health, PT/OT, homemaker services, etc. are all coming and on time.
Connects with interdisciplinary team members as appropriate (physicians, specialists, pharmacist, home health, family caregiver, etc.)
Utilizes psycho-therapeutic techniques to increase patient motivation; to decrease client/caregiver stress and anxiety, and address potential mental health concerns.
Connects the client/family to community resources and long-term services and supports.
Keeps statistical client data necessary for appropriate records and reports to manager.
Projects good image for agency.
Maintains credibility and integrity of organization.
Performs all other duties as assigned.
MSW or advanced degree in related human service field
2 years of experience in healthcare, social services or related field
Positive cooperative attitude.
Comprehensive social work assessment skills
Willingness to serve as an advocate for client’s rights.
Interpersonal communication and rapport development skills with older adults, family members and interdisciplinary teams
Cultural competency of the community served; bilingual/bicultural as appropriate to the community
Familiarity with state, federal and local community resources
Client-centered, motivational, and empathetic interviewing skills
Computer literacy (Microsoft Office suites)
Willingness to travel while on the job.
Possess a valid driver’s license in the state of Illinois.
Access to a vehicle in good mechanical condition and maintain insurance.
Clean and well groomed.
Ability to follow instructions.
Ability to keep records and independently manage time.
About Senior Services of Will County
Senior Services of Will County has been providing assistance and resources to older Americans in their region for more than fifty years. This includes programs that proactively equip and strengthen seniors to live independently as well as working with those who are home bound and in greater need of assistance. We connect individuals age 60 or older to resources, information, services and programs to keep seniors safe, healthy and independent.