Health Services Coordinator, Bethany Senior Terraces (48720)

ESSENTIAL DUTIES AND RESPONSIBILITIES

Under the general supervision of the Supportive Housing Programs Supervisor, the Health Services Coordinator at Bethany Senior Terraces is responsible for providing ongoing support services for frail elderly tenants exiting shelters into permanent affordable housing. The Health Services Coordinator will be part of a team that connects tenants to the health and community building services that ensure they can age safely in their homes and communities. Specific duties and responsibilities include:

• Serve as part of a team comprised of Case Manager, Health Services Coordinator, and program supervisors to serve frail previously homeless older adults
• Conduct assessment of the health needs of each resident including identifying barriers to access to health services and health related resources in the community
• Create a health and wellness action plan tailored to each client’s needs, working collaboratively with healthcare providers and other community-based organizations to ensure client receives comprehensive and coordinated care and an increase access to healthcare services
• Promote health, prevention, and wellness informational activities for residents specific to their determined health needs
• Provide access to educational resources in order to increase client awareness of social determinants of health outcomes as well as how to manage chronic conditions
• Together with the Case Manager, provide education on insurance options available to residents, including eligibility criteria, and how to access/renew benefits
• Collaborate with Case Manager to support resident service plan goals and participate; participate in case conferences to discuss resident needs and action plans
• Provide clients with ongoing follow-up, conduct motivational interviews, and assist with health goal setting
• Create a network of community medical and mental health providers and resources; provide information and referrals to clients as needed
• Assist clients with medication review and understanding directives from Primary Care Physicians (PCPs) in order to address chronic health conditions and decrease utilization of hospitals and other high-cost interventions
• Provide consistent communication to clients via Friendly Visits (FV) and Telephone Reassurance phone calls (TR)
• Coordinate transportation resources for medical appointments and provide appointment reminders as needed
• Assist residents in coordination of medical services and escort tenants to appointments when appropriate and based on need
• Assist residents in accessing necessary medication as well as any medical equipment that will ensure resident safety and housing stability
• Together with the Supervisor, organize curriculum for health and wellness educational workshops for residents
• Facilitate health-focused workshops and presentations based on resident needs and feedback
• Coordinate with healthcare systems and institutions to track hospitalizations, outcomes, and create an action plan based on the providers’ recommendations
• Track and report on the outcome of referrals and the impact of services on resident health and housing stability
• Other r