Transition Coordinator

Department: Money Follows the Person (MFP)

Status: Full-time, Monday-Friday (Hourly Non-Exempt)

SUMMARY

For over forty-five years, the Agency on Aging of South-Central Connecticut (AOASCC) has been helping people age in their homes and remain engaged with their communities. We serve older adults, people with disabilities, and caregivers through various programs to provide care management, social services, assistance with government benefits, volunteer opportunities, and advocacy. We continue to grow and develop new programs to reach more community members who need our support.

The transitional programs of AOASCC provide support to individuals with disabilities and frail older adults to assist them in remaining safely in their own homes. As transitional coordinator, you will provide crucial support to individual clients within the community and specialized care managers, ensuring continued quality of care for our clients. This position will work in the office but does require travel to individual Client homes.

Provide assistance and support to institutionalized clients willing and able to return to their home in the community safely.

Assist the Specialized Care Manager (SCM) in determining transition challenges and establishing a target discharge date and follow-through on an action plan.

Assist clients with benefits and entitlements, including Medicaid and Social Security application processes.

Coordinate home modification process and Schedule-transition transportation.

Request the PT/OT evaluation and the ordering of DME, follow up with the facility social worker.

Complete the transition plan and budget if needed.

Oversee the transition day and record the transition by notifying the Central Office on the same day.

Post-transition interviews at 3, 30, 60, and 90 days (face-to-face or phone, according to client's preference).

Establish relationships with the local community providers, access agencies, DSS social workers, and other organizations.

Serve as liaison between the providers, access agencies, DSS social workers, other community-based program organizations, and the State's transition program.

Engage in outreach activities at nursing facilities to inform residents and staff about the transition program.

Conduct initial interviews and complete intake paperwork with people in nursing homes and other institutional settings.

Assist each participant with the development and implementation of a transition plan.

Coordinate plans and make referrals to appropriate community resources.

Assist participants as needed with activities related to transition day such as shopping, packing, Loading, and moving personal belongings, hanging curtains, and assembling furniture.

Complete and submit the required documentation and reports on time, internally and to outside agencies such as The Department of Social Services (DSS)

Skills and Experience including but not limited to:

Bachelor's degree in Human Services or Related Field

Minimum of One years of related experience

Experience in systems advocacy and community organizing.

Ability to write routine reports correspondence and use a web-based reporting system.

Ability to write/document concisely and legibly.

Professional work ethic, appearance, and demeanor required.