Geriatric Care Manager SCO CCA

Geriatric Support Services Coordinator

The Geriatric Support Services Coordinator (GSSC) is the care manager assigned to work with SCO enrollees and is a member of the Primary Care Team (PCT). The GSSC is responsible for coordinating and providing community social services to SCO enrollees who are the frailest elders by the SCO's policies, procedures, and practices. The GSSC assists the PCT or PCP in promoting the SCO enrollee's independent functioning in the most appropriate, least restrictive setting. GSSCs are expected to be on-site at B.U. Geriatrics two days per week.

Essential Functions and Responsibilities:

• As a member of the Primary Care Team (PCT), participate in Initial and Ongoing Assessments of the health and functional status of enrollees, including determining appropriateness for institutional long-term care services and developing community-based care plans and related service packages necessary to improve or maintain an enrollee's health and functioning.
• Arrange, coordinate, and authorize the provision of appropriate long-term care and social support services for enrollees (with the agreement of the PCT and by requirements set forth by the SCO). These may include but not be limited to: ADL and IADL assistance; Housing; Home-delivered Meals; and Transportation.
• Monitor the appropriate provision and functional outcomes of community long-term care services that have been authorized by the PCT.
• Track enrollee transfers from one setting to another (for example, hospital to home or nursing home to adult day health) and adjust service plan as deemed appropriate by the PCT and by requirements set forth by the SCO.
• When an enrollee resides outside of the catchment area, coordinate information with local ASAP outside of Boston; otherwise visit enrollee in Boston neighborhoods not served by CBES
• Participate in case conferences with the PCP, Nurse Care Managers, and representatives from other disciplines to identify the optimal plan of care for SCO members.
• Participate in all required training by the SCO and CBES
• Respond on time to enrollee service requests
• In collaboration with the PCT, the enrollee, the enrollee's designated representative, and providers of community-based services in determining appropriate discharge plans after admission to an institution
• Prepare documentation for enrollee files and ensure appropriate time entries and updates of enrollee information available in the Centralized Enrollee Record (CER).
• Have a working knowledge of SAMS, Altruist (CCA database), and Epic (BUGS database) to enter and retrieve data.
• Perform all services by state and federal law and written SCO management protocols.
• Attend and participate in agency and departmental meetings and trainings as required
• Other duties as assigned.

Qualifications:

• Have the knowledge and skills necessary to work successfully in an interdisciplinary team and to provide or arrange community long-term care.
• Have the ability to assess clients and their needs and knowledge of the community-based service network.
• Possess excellent interpersonal and problem-solving skills
• Have the ability to work with a diverse population
• Access to car desirable

Education:

• A Bachelor's degree and two years of professional experience working with persons aged 65 or older.
• One year of experience involving work in a setting where persons over 65 receive health-care services. (such as (such as a hospital, nursing facility, community health agency, or interdisciplinary program within an ASAP);
• Be a social worker licensed by the Commonwealth of Massachusetts, with annual and continuing education units in geriatric practice.

Physical Requirement of the Job:

• Ability to lift and carry objects frequently weighing between 10-15 pounds.
• Ability to climb stairs.
• Ability to travel to the community to perform visits at consumers' homes.
• Work requires regular standing, stooping, and bending.