Position Overview

The Enhanced Service Coordinator (ESC) is a three-year, grant-funded position under the U.S. Department of Housing & Urban Development’s Supportive Services Demonstration (SSD). Any funding for the continuation of the ESC position, including any augmentation, is subject to the availability of funds after the demonstration ends.

The ESC will proactively engage with all SSD participants in a comprehensive, proactive and on-going manner to assess and identify resident needs, develop and implement individual healthy aging plans, actively motivate and educate residents on self-management of chronic conditions, and promptly implement transition plans in close collaboration with hospitals and nursing homes. The ESC serves as the primary manager of the HUD supportive services demonstration and is the central point of communication and coordination. Employing a person-centered approach, the ESC works in concert with each participant and their family members, if appropriate. The ESC creates partnerships with community health and social services partners and health care providers facilitating care management meetings to insure that the most complex situations are tightly coordinated across partner organizations while the aggregate needs of the residents are supported through evidence-based practices. The ESC’s job is to help residents address needs, achieve their self-identified goals, and support their ability to safely age in place. The ESC also acts as the primary liaison between the housing property and the SSD Implementation and Evaluation Teams.

Responsibilities/Functions

Serve as the central coordinator and communicator for the supportive services demonstration within the housing community.

Serve as a liaison to the external community, helping to educate community organizations about the supportive services program, and develop partnerships.

Establish and execute outreach processes, along with the WN and property management staff, to educate residents about and facilitate enrollment in the supportive services demonstration.

Enroll residents in the supportive services demonstration, including explaining all privacy and confidentiality protections.

Oversee an initial and on-going resident assessment process, including conducting person-centered interviews to understand resident lifestyles and interests, and collaborating with the WN to complete a resident health and wellness assessment that gathers information about resident physical, mental, functional, and social status.

Develop individual-level and community-wide healthy aging plans, with input from the WN and resident, to address identified interests and needs. Plans are guided by information from the individual assessments, summary reports of aggregate needs pulled from the data platform, personal observations, and input from partners.

Organize and coordinate on-site wellness and health improvement programs, events, and activities.

Oversee ongoing implementation of the individual and community healthy aging plans, with the ESC and WN each fulfilling specific roles.

Engage and motivate residents, including socially isolated individuals, to enroll in the program and be active participants in improving/maintaining their health and well-being.

In collaboration with the WN, review discharge plans to help ensure timely follow-up of needed supports and coordination of care for residents discharged from the emergency department, hospital, skilled nursing facility, or home health care.

Assist residents to ensure the ongoing delivery and receipt of services and periodically assess residents for new assistance and care needs in response to changing circumstances.

Assist residents in identifying and accessing needed services and benefits, and serve as a liaison or advocate for residents when help is needed to secure resources.

Establish informal and formal partnerships with health and supportive service agencies in the community to ensure that the necessary services are available and delivered in a collaborative and efficient manner.

Establish and maintain communication channels with the WN, community partners and property management staff to appropriately share information concerning residents and identify ways in which resident needs can be efficiently addressed.

Convene and facilitate team meetings that may occur with the WN and/or community partners to triage resident needs and develop strategies to efficiently address and coordinate service needs.

Produce program materials, such as a periodic resident newsletter.

Maintain all necessary resident and program data in the electronic data platform, including information from the person-centered interview and health and wellness assessment, interactions with residents, resident participation in programs, and sentinel resident events (e.g. falls, ED visits, etc.).

Maintain and share all personal resident information in accordance with applicable privacy and confidentiality requirements.

Collaborate with the SSD Implementation and Evaluation Teams, including participating in all trainings, to the greatest extent possible; engage in peer-to-peer learning activities; engage in a quality assurance process; and participate in interviews, surveys, or other evaluation activities.

Functions NOT ALLOWABLE:

Provide direct services to residents.

Engage in care management activities that duplicate services provided by other agencies, unless necessary to meet the immediate needs of a resident.

Act as a recreational or activities director.

Act as a Neighborhood Networks program director or coordinator.

Perform property management tasks.

Required/Minimum Qualifications

A Bachelor of Social Work or degree in gerontology, psychology or counseling. Other college degrees and/or work experience may be substituted, as appropriate.

Respect for and comfort with allowing individuals to make their own decisions and prioritize their own care goals.

Understanding of and sensitivity to the needs of low-income older adults and persons with disabilities.

Ability to self-direct and work independently, but also function well as part of a team.

Ability to multi-task and establish priorities in a sometimes busy and stressful environment.

Ability to establish positive and collaborative relationships with residents, staff and community-based providers.

Basic computer proficiency, including ability to maintain data in an electronic database, communicate via e-mail, use internet, and operate word processing software to create program materials.

Preferred Skills

Knowledge of supportive services and other resources available in local area served to help assist low-income older adult.

Ability to translate jargon into easily understandable language and to communicate at appropriate literacy and cognitive levels.

Strong verbal, written, and interpersonal communication skills.

Familiarity and understanding of working with individuals with mental health needs.

Cultural competency in working with diverse populations and individuals from different ethnic and racial backgrounds, including working with non-English speaking adults.

Experience conducting comprehensive needs assessments and developing/implementing plans to help address identified needs.

Experience building relationships and partnerships with local service providers, community institutions, and government agencies.

Experience using motivational interviewing, active listening, and person-centered care concepts to help encourage individuals to engage in addressing and managing their own care needs.

Understanding of affordable housing operations and fair housing practices.

Understanding of using data to monitor and improve program practices and operations. Experience and enthusiasm for working with older adults.

Bi- or multi-lingual in languages most commonly used by residents at the property.