SASH Coordinator

Job Overview

The primary function of the Support and Services at Home (SASH) Coordinator is to build trusting relationships with SASH participants and develop a thorough understanding of each participant’s strengths and challenges as they pertain to living safely at home. The SASH Coordinator convenes the on-site SASH team on a regular basis to coordinate care and services to meet the needs of SASH participants.

Essential Duties and Functions

• Organize informational meetings and materials for promoting and explaining the SASH model to residents and their family members/supports.

• Thoroughly explain the Use and Disclosure Agreement and related documents to residents and their family members/supports.

• Responsible for following all policies and protocols established for SASH as found in the SASH Operations Manual.

• Develops and maintains a regular Community Healthy Living Plan (CHLP) calendar of wellness activities and events for participants.

• Help participants build support networks with other participants, friends, volunteers, and family members.

• Adhere to confidentiality guidelines and appropriate document information releases.

• Recruit, train and supervise volunteers in the provision of activities and programs in the CHLP.

• Establish and maintain good working relationships, ongoing liaison with, and an in-depth knowledge of the services available from community organizations including, but not limited to, the Agency on Aging, VNA/Home Health and Hospice, local hospitals, nursing homes, senior centers, volunteer groups, etc.

• Participate in community outreach and marketing activities regarding SASH.

• Work independently and as part of the SASH team and the housing team to carry out job duties.

• Communicate in a positive and respectful manner with participants, community members, co-workers, volunteers, visitors, and family members.

• Communicate effectively and respectfully with inter-agency colleagues.

Principal Responsibilities by Intervention Category

Specific roles and responsibilities of the SASH Coordinator fall into three broad categories of interventions that the SASH model integrates to provide SASH participants with a holistic, person-centered approach. These three intervention categories are Transitional Care Interventions, Coordinated Care Interventions, and Self-Management Education Interventions.

Transitional Care Interventions

• Educate and inform SASH participants and family/support persons of the SASH Admitting and Discharge Planning Protocols.

• Follow all designated SASH Coordinator duties outlined in the Admitting and Discharge Planning Protocols including:

• Coordinate and communicate with discharge staff at off-site facilities.

• Communicate with family members/caregivers and make visits to participants in hospital or rehab facility as appropriate.

• Update SASH team on participant’s transition status and confirm services to be available upon discharge.

• Make an 104769in-person visit to participant within 24-48 hours of returning home to identify needs and review discharge instructions.

• Coordinate and plan for any needed and unmet services with SASH team.

• Update participant’s SASH health record and Healthy Living Plan (HLP).

Self-Management Education Interventions

• Develop the Community Healthy Living Plan (CHLP) in collaboration with the SASH team and revise the CHLP Action Plan every six (6) months based on ongoing assessment of the needs and opportunities of the participant community.

• Identify how best to offer CHLP services/programs for SASH participants (e.g., bring existing community-based programs on-site, assist participants to participate in off-site programs, design new programs).

• Provide encouragement and “coaching” to help participants keep focused and motivated on proper self-management of their chronic conditions.

• As requested, or agreed to by participants, provide reminders and/or daily check-ins to promote self-management skills.

• Organize and coordinate on-site educational presentations on health and well-being topics based on the collective needs of the SASH participant population as outlined in the CHLP.

• Coordinate and oversee volunteers (in collaboration with the Volunteer Coordinator if applicable) to support participants in meeting their HLP goals.

Coordinated Care Interventions

• Arrange and schedule assessments of SASH participants to determine health and functional needs.

• Conduct person-centered interviews with all SASH participants to understand their interests, needs, ideas, concerns, and opinions.

• Coordinate the development of Individual Healthy Living Plans (HLPs) in collaboration with the SASH team.

• Meet with SASH participants to discuss, gather input, and finalize HLPs.

• Coordinate and assist SASH participants with individual support needs and goals as identified in the HLP.

• Act as key contact person on-site for information sharing regarding SASH participants among the SASH team, Wellness Nurse, discharge planning staff from hospitals and rehab facilities, family members, and volunteers.

• Convene SASH team meetings - set agenda, lead meetings and keep (or delegate) summary notes following a structured team meeting format.

• Contribute information in the progress notes section of the SASH participant’s Health & Wellness Record.

• Communicate regularly and deliberately with SASH participants one-on-one and in groups to ensure consistent follow-up and information sharing among the SASH Coordinator, Wellness Nurse, SASH team and SASH participant.

• In communities where a Personal Care Attendant (PCA) is contracted for on-site services, they provide introductions to SASH participants and functional supervision to PCA in collaboration with Wellness Nurse and contracting agency.

• File PCA reports in the nurse’s office.

Minimum Qualifications

• Must possess a high school diploma; bachelor’s degree in social work or a related field is preferred.
• Previous experience coordinating services specifically for older adults and/or people with disabilities.
• Knowledge of area resources and programs available to older adults and people with disabilities (e.g., transportation, health services, recreational and wellness activities)
• Demonstrated excellence in verbal and written communication.
• Must possess a valid driver’s license.
• A working knowledge of Microsoft Word, Access, Outlook, and Publisher.
• Must be accepting of health conditions and behavior of participants.
• Must be adaptable to working in an ever-changing, high-pressure work environment.
• Computer software and statistical databases in general are highly desirable.