Job Summary:   The CSSM (Comprehensive Screening and Services Model) Care Advisor, as part of the Interdisciplinary Discharge Planning Team (IDPT), will identify consumers with potential for safe discharge from a Skilled Nursing Facility (SNF) setting back to the community.

Authority:             This position reports to and is supervised by the Home Care Department.

Qualifications:  

• Bachelor’s Degree
• Knowledge and experience working with elders and individuals with disabilities
• Knowledge of community based services (Mass Health, state agencies and various providers) for elders and persons with disabilities
• Minimum of one year experience transitioning individuals from nursing facilities or long-stay hospital to community based settings

Duties and Responsibilities:

1. As part of the CSSM team and jointly with the CSSM RN, the CSSM CA will visit each of the eight skilled nursing facilities (SNF) in Highland Valley Elder Services (HVES) catchment area on a weekly basis to attend a regularly scheduled meeting with SNF SWs/ Discharge

The CSSM CM will:

• Obtain an Admission List from each SNF consisting of all admissions from the previous week, including consumers who are Mass Health Members or
• Participate in discussions regarding above consumers to identify feasibility of a safe discharge
• Participate in discussions regarding any consumer previously granted a Short Term Clinical Eligibility Determination in order to monitor the consumer’s progression toward
• Jointly with the CSSM RN and following an IDT meeting, the CSSM CA will meet with the resident and/or family to accurately identify the resident’s community service needs, educate the resident and/or family about community services and develop the community service
• Coordinate, arrange and track identified
• Attend Care Planning and Discharge Planning Meetings on behalf of identified
• Coordinate discharge planning with SNF SW/Discharge
• Complete documentation of all meetings, actions, case conferences, regarding community alternative considerations according to HVES documentation standards. Complete monthly and quarterly reporting to comply with Mass Health Standards.
• Complete all required tracking of successfully discharged consumers in order to ensure the consumer’s service plan is appropriate and adequately meeting his/her care needs via the Case Closure Tracking Form (CCTF) in SIMS
• Conduct Initial Assessments, post-hospitalization visits as needed, to support the Home Care Program
• Participate in training and development activities to increase knowledge/skills for continuous strong performance in this position
• Other tasks as assigned by supervisor to meet agency needs.

ADDITIONAL JOB REQUIREMENTS

• Other tasks as assigned by supervisor to meet agency needs.
• Environmental Conditions: Work is 50% indoor office work; 50% outdoor (i.e. travel to attend required meetings, presentations and trainings).
• Physical Requirements
  • While performing duties of position, employee will be required to sit/stand for extended periods.
• Working knowledge of computers applicable software and databases and capacity to see computer screen and read written material.
• Capacity to communicate verbally with staff/supervisors, consumers and community.
• Capacity for the fine manipulation of office equipment.
• Capacity for occasional reaching, lifting or bending.
• Work Environment Expectations
• Available to work an hourly position with primary hours daily M-F, 9am-5pm.
• Ability to drive as the position requires.

Essential Functions and Responsibilities:

Qualifications:

TITLE:                          Nurse

JOB SUMMARY:        Conduct clinical assessment on seniors and determine eligibility for programs. Establish and/or maintain working relationships with area home-health agencies, health care facilities and skilled nursing facilities.

AUTHORITY:              Reports to the Nursing Programs Manager

REQUIREMENTS:      RN, BSN or AD with a minimum of two years of experience in a community or long-term care setting.

PRIMARY FUNCTIONS AND RESPONSIBILITIES INCLUDE, BUT ARE NOT LIMITED TO:

1. Conduct Clinical Assessments on seniors.
2. Determine Eligibility for a variety of Programs.
3. Provide ongoing education and consultation to ASAP Case Management staff and area health providers regarding clinical eligibility criteria for ASAP and MassHealth programs and services.
4. Function as liaison to administrative staff at home health agencies, area skilled nursing facilities, and Executive Office of Elder Affairs clinical staff.
5. Attend applicable staff and/or agency meetings.
6. Participate in training development activities to increase knowledge/skills for continuous strong performance in this position.
7. Participates in required quality performance initiatives within responsible program areas.
8. Perform other tasks as assigned by supervisor to meet agency needs.

Additional Job Requirements

1. Environmental Conditions: Work is 75% indoor office work; 25% outdoor (i.e. travel to consumers and attend required meetings).
2. Physical Requirements
   1. While performing duties of position, employee will be required to sit/stand for extended periods.
   2. Working knowledge of computers applicable software and databases and capacity to see computer screen and read written material.
   3. Capacity to communicate verbally with staff/supervisors, consumers and community.
   4. Capacity for the fine manipulation with use of office equipment.
   5. Capacity for occasional reaching, lifting or bending.
3. Work Environment Expectations
   37. Available to work an hourly position M-F, 9am-5pm. 5 hours per week.  Employee (full benefits) or Per Diem.   $30 per hour
   38. Ability to drive own vehicle as the position requires.

Essential Functions and Responsibilities:

Qualifications:

JOB SUMMARY:        The Protective Service Worker performs intake, investigation and service

planning and other Protective Services casework functions under the Elder

Protective Services Program as defined in 651 CMR.5.02.

AUTHORITY:              This position reports to and is supervised by the Highland Valley Elder Services Protective Services Program Director.

REQUIREMENTS:      A Masters or higher degree from an accredited school in social work, psychology, counseling, human development, nursing or gerontology; plus at least 1 year of experience in counseling casework or case management, preferably in a Protective Services or crisis intervention capacity. OR Bachelor’s Degree from an accredited school in social work, psychology, counseling, human development, or gerontology; plus at least 2 years of experience in counseling, casework or case management providing protective or crisis intervention services.

PRIMARY FUNCTIONS AND RESPONSIBILITIES INCLUDE, BUT ARE NOT LIMITED TO:

• Receives reports of the abuse, neglect, self-neglect and financial exploitation of elders and conducts an investigation to determine whether there is reasonable cause to believe that the abuse occurred.
• Determines whether an emergency or non-emergency situation exists and responds to emergency situations when necessary, within working hours or as negotiated.
• Conducts protective assessments of abused elders, including evaluation of the functional capacity, situation and resources of abused elders, in accordance with the provisions of M.G.L. c. 19A and 20(a) or 20(b).
• Develops, with abused elders, protective service treatment plans; and provides or arranges for the provision of protective and other services to abused elders.  Provides counseling to elders regarding the alleviation or prevention of abuse and the availability of services.  This can involve work with the Probate Court or District Attorney's Office.
• Monitors the provision of services necessary to alleviate abuse and neglect, until the case can be closed.
• Maintains the case file by completing all mandated paper work in a timely fashion, according to required documentation standards, including the full use of APS computerized record (Harmony).
• Performs community organization work to help educate the community to the issue of elder abuse; and develops the effective inter-agency relationships necessary, in order to utilize the multi-disciplinary resources available in the community for abused elders.
• Responsible for after-hours, on-call coverage 1 week at a time, to be shared with other staff on a rotating basis.
• Provides back-up to care management system as needed.
• Responsible for carrying out other duties as assigned by the Protective Services Program Director.
• Participates in training and development activities to keep up with knowledge/skills leading to strong performance in this position.
• Participates in required quality performance initiatives within program area.

ADDITIONAL JOB REQUIREMENTS

• Other tasks as assigned by supervisor to meet agency needs.
• Environmental Conditions: Work is 50% indoor office work; 50% outdoor (i.e. travel to attend required meetings, presentations and trainings).
• Physical Requirements
  • While performing duties of position, employee will be required to sit/stand for extended periods.
• Working knowledge of computers applicable software and databases and capacity to see computer screen and read written material.
• Capacity to communicate verbally with staff/supervisors, consumers and community.
• Capacity for the fine manipulation of office equipment.
• Capacity for occasional reaching, lifting or bending.
• Work Environment Expectations
• Available to work an hourly position with primary hours daily M-F, 9am-5pm.
• Ability to drive as the position requires.

Essential Functions and Responsibilities:

Qualifications:

JOB SUMMARY:  To increase living options for elders by developing, implementing and monitoring a service plan, using a comprehensive assessment procedure, which will best assist an elder to maintain the living arrangement of his/her choice.

AUTHORITY:  This position reports to and is supervised by the Home Care Program Director and the Home Care Supervisor.

 DUTIES AND RESPONSIBILITIES:

 Link and coordinate resources with elders.

 Make comprehensive assessments through field interview and observation. Conduct monitoring visits at regular intervals and as needed.

1. From this assessment, develop and implement a service plan, make referrals to appropriate agencies and follow up on these referrals.
2. Act as an advocate to/with the consumer when necessary.
3. Maintain the case file by completing all mandated paperwork in a timely fashion according to required documentation standards.
4. Provide Information and Referral services.
5. Participate in Highland Valley's development of comprehensive community programming efforts.
6. Participate in training and development activities to increase knowledge/skills for continuous strong performance in this position.
7. Participate in required quality performance initiatives within program area.

Essential Functions and Responsibilities:

Qualifications: