Geriatric Care Coordinator - UPMC Division of Geriatric Medicine

UPMC•Pittsburgh, PA

3h•Onsite

About The Position

University of Pittsburgh Physicians is hiring a Full-Time Geriatric Care Coordinator to help support the UPMC Division of Geriatric Medicine. Hours: Monday-Friday, daylight. Location: Kaufmann Medical Building Department Details: This position provides support for older adults with dementia as part of a CMS program designed to help them stay in their home. It involves a comprehensive assessment by a physician or APP, then the Care Coordinator does a home assessment mostly focused on safety and how the patient manages in their own setting. This is followed by monthly outreach to provide support, caregiver education, and training, and help with obtaining resources for patients and caregivers. This individual should be able and willing to drive to patient homes in Allegheny and surrounding counties. The following experience is preferred, but not required: Previous experience with older adults, and excellent verbal and written communication skills. Purpose: Manage an active caseload of elderly clients in their designated geographical areas. Serve as the care coordinator, performs assessments and re-assessments, interacts with clients with physical, social and mental health problems together with their families or significant others to coordinate and monitor delivery of care provided by the volunteers and public and private agencies.

Requirements

B.A. degree in Social Work, Psychology, or related fields preferred or 8 years' experience in health and human services agencies, information and referral services for older adults or related health care experience.
Excellent oral and written communication skills.
Knowledge of computer programs used for data collection, internet search and other applications.
Ability to work with persons with physical and mental health problems.
Ability to work independently and handle several responsibilities at one time.
Knowledge of the assigned service area and resources within that service area.
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Nice To Haves

Previous experience with older adults
Excellent verbal and written communication skills

Responsibilities

Regularly document progress of clients into the computer system. Maintain confidential client records, statistical data and quality assurance indicators. Provide reports on the program community activities, utilization statistics and quality improvement indicators.
Independently manage and monitor a caseload of between 60 and 120 clients within the given geographic area as outlined in the program guidelines.
Respond to hospital discharges and community referrals in a timely manner.
Coordinate services needed by the client with private and public service providers including all service lines of UPMC. Seek input from all the health care providers involved in the care of the client in developing the care plan for the client.
Represent the Program to the community, neighborhood groups and other professional organizations. Communicate with the director of the neighborhood organization with whom the community worker is affiliated or placed.
Develop and implement a care plan based on the initial assessment. Conduct reassessment as defined in the program guidelines and revise the care plan as needed.
Recognize clients with special needs and problems that require referral to the interdisciplinary care coordination team. Routinely provide input into the interdisciplinary care meetings, communicate with the attending physician as needed to provide input and seek direction for plan of care.
Attend all staff meetings, in-service training workshops on a regular basis including programs offered by the University of Pittsburgh Institute on Aging such as the Gerontology Certificate program and other programs in gerontology care coordination.
Assist the client and the family member with care needs during transitions of care from one level to another. This may include seeking information from the hospital/ nursing facility/ rehab facility upon discharge or providing information to the hospital/nursing facility/rehab facility upon admission. Organize service augmentation for cases transferred to other service providers to assure a smooth transition.
Identify volunteers of all ages in the community for referral to the volunteer coordinator. Confer with volunteer coordinator regarding volunteer placement, development and evaluation.
Assist in training of new staff.
Independently structure workload to ensure that all clients are visited and called within the timeframes outlined in the program guidelines.
Engage the client in taking care of their health by assisting the client to update and maintain personal health care information such as a health care diary. Assist them to use such information in communicating their health care needs with their physician and other health care providers.