The basic function of the Case Manager is to (1) assist elders in obtaining services that will secure an independent lifestyle, (2) identify gaps in services and advocate for services that will maximize independent functioning and (3) to educate and promote awareness of community services.

Responsibilities:

• Conduct an initial assessment of physical, social, environmental and emotional status to determine needs and eligibility requirements within EOEA time frame guidelines.
• Develop service plan and supportive networks through contact with client, formal and informal supports, and consultation with supervisor.
• Implement service plan by telephone immediately followed by authorization to provider agencies.
• Assist client to obtain and utilize other community services such as: VNA, housing, fuel assistance, council on aging, Medicaid, etc.
• Monitor client’s needs and service plan on an ongoing basis.
• Participate and recommend client’s for ICR meetings as needed.
• Provide support and information to client and those directly involved in client’s care. Encourage self advocacy.
• Keep the files up to date, includes changes in services and observations. The files should include copies of all correspondence with client.
• Keep journal notes up to date, including summary of telephone contacts, service changes and calls concerning client
• Complete authorizations, notices of suspension, and termination and other related forms in a timely manner.
• Record statistical data. Accurately complete monthly reports.
• Verify client file information for the annual hand count for EOEA.
• Update knowledge pertaining to gerontology and services for elders through courses, and in services.
• Participate in staff meetings to discuss home care and other related issues.
• Meet with supervisor on a regular basis.
• To work with and monitor in-house programs and vendors. Conduct ongoing client satisfaction and vendor observation visits and complete the appropriate corresponding forms.
• Perform miscellaneous duties and assignments as directed by immediate supervisor.

Essential Functions/Qualifications:   

• Regular and reliable attendance.
• Bachelor’s degree in Social Work Human Services or related field preferred
• Organizational and time management skills.
• Communication Skills with consumers, physicians, family members, providers (telephone, email or in person, as needed).
• Communication skills with funders, state and federal agencies, ASAPs.
• Communications skills with employees.
• Cultural competency and the ability to provide informed advocacy.
• Knowledge of home and community-based service systems and how to access and arrange services (preferred).
• MassHealth programs (preferred).
• Public benefits.
• Familiarity with state-wide health care network (preferred).
• Written communication skills.
• Demonstrated analysis and problem-solving skills.
• Meet deadlines in a timely fashion.
• Able to develop and maintain positive effective relationships with providers, consumers, and the public.
• Problem solving skills.
• Works as a member of a team and independently.
• Motor vehicle.
• Valid Driver’s license; maintain minimum insurance liability on vehicle and complete motor vehicle driving record check.
• Accurate record keeping skills.
• Maintain Confidentiality.
• Attention to detail.
• General office procedures.
• Consumer Advocate.
• Computer Acuity.
• Software: Windows, Excel, Power Point, Outlook.
• Ability to be flexible and work in a fast-paced environment.
• Maintain caseload/production at program/department standards.
• Physical Demands:
• Computer access.
• Ability to traverse homes, yards and stairways.
• Must be able to sit for periods of time at computer or while driving.
• Must be able to carry files of up to 5 pounds and laptop.
• Occasional bending, reaching, twisting, standing and climbing.
• Frequent Standing and walking.

Work Environment:

• Traditional office environment including work from home along with meeting consumers at their homes or in public places

The Meals on Wheels Driver is responsible for a home delivered meal route and related jobs at the Nutrition Center.

Responsibilities:

• Count and pack food trays for home delivery.
• Count and pack hot and cold food products into carriers.
• Assist coordinator with wrapping bread, packaging desserts, etc.
• Deliver meals to homebound participants and maintain records for routes.
• Maintain paperwork and report any emergencies or changes in participant status to the Nutrition Center Coordinator or Meals on Wheels Coordinator.
• Clean meal delivery equipment daily.
• Other duties as assigned.

Essential Functions/Qualifications:

• Must have valid driver’s license, good driving record and required insurance coverage.
• Must have a motor vehicle.
• Accurate record keeping skills.
• Ability to work well with older adult participants.
• Ability to learn delivery routes and capable of training other drivers.
• Capable of handling emergency situations and able to maintain confidentiality.
• Ability to climb/descend stairs and navigate potentially uneven terrain (walkways, driveways, etc.)
• Ability to lift equipment up to 40 pounds.

The basic function of the Case Manager for Adult Family Care Bilingual (Arabic) is to provides social work and case management components in the Adult Family Care Program.

Responsibilities:

• Completes Central Intake Form and Participant Referral form in a timely manner.
• Assists team nurses with completion of the CDS-HC Assessment Tool for new AFC referrals. Obtains Release of Information form signature at time of assessment.
• Facilitates and participates in making recommendations with respect to matching clients with caregivers at clinical team meetings.
• Facilitates and participates with team nurses in the development of plans of care for clients, giving attention to psychological behavior, social needs and discharge plans including transfer to another AFC home.                                                     
• Will provide translation services for TV staff, as needed.
• After acceptance into the AFC Program, the Program Director and/or Social Service Caseworker advises caregivers/clients with respect to community psych/social resources. Makes referrals, coordinates and monitors services they receive, as needed.  These services may include counseling, social day care, adult day health, workshops, transportation and other social needs.           
• Obtains all necessary client financial information for each program according to orientation form.
• Discusses the program financial requirements with clients and families and provides initial  teaching and on-going financial management assistance.  Initiate referrals for rep-payee appointment, if necessary.                                                       
• Assists clients with making funeral arrangements and/or arranging burial accounts upon admission into the AFC Program and incorporates this into the written plan of care.
• Arranges alternate care for clients, including planned vacations and in emergency situations.
• Maintains an up-to-date record keeping system, with regard to the affairs of clients and caregivers. This includes written monthly progress notes and other communication as needed.
• Interviews and evaluates caregivers through home assessments to determine suitability of home and the potential caregivers’ abilities.
• Completes yearly caregiver evaluations in conjunction with the AFC RN and Program Director. Conducts evaluations with caregivers and obtains necessary signatures.     
• Performs monthly financial updates by monitoring bankbooks and ledgers, ensuring that the combined balances do not exceed $2,000.00.
• Advocates for and completes all necessary documentation with respect to Social Security, Medicaid, SSI and post-eligibility application requirements, including Medicaid spend down  and re-determinations, and taxes, if necessary.                     
• Responsible for obtaining and updating signed client/caregiver contracts as needed.
• Develops and maintains detailed fire plan for caregiver homes. Conducts quarterly fire drills            in the home and completes the “Fire Drill Log” in the home notebook.          
• Participates in or conducts training and on-going supervision of caregivers and psych/social aspects of client care.

General:

• Assists with clinical orientation of new personnel with regard to operational policies and procedures.
• Actively participates in monthly team meetings, providing updates on each placement and other pertinent information relevant to AFC.
• Participates in Program Outreach including presentations, information dissemination and other activities as directed.
• Works cooperatively with other agencies in the health and elder network and represents AFC at meetings, as necessary.
• Participates in the Mass Council for AFC meetings in order to network with other AFC programs as directed by Program Director.
• Accesses training opportunities pertinent to the AFC program and its psych/social component.
• Strives to enhance and maintain the morale and enthusiasm of team effort.

Essential Functions/Qualifications:

• BA/BS in relevant field is preferred.
• Bilingual (English/Arabic)
• Must submit results of a physical exam completed within the past 12 months.
• Must submit documentation of a tuberculosis screening within the previous 12 months.
• Regular and reliable attendance.
• Organizational and time management skills.
• Communication Skills with employees, consumers, physicians, family members, providers (telephone, email or in person, as needed).
• Communication Skills to include public speaking.
• Cultural competency and the ability to provide informed advocacy.
• AFC program.
• Quality improvement.
• Written communication skills.
• Meet deadlines in a timely fashion.
• Able to develop and maintain positive effective relationships with providers, consumers, and the public.
• Works as a member of a team.
• Works independently.
• Motor vehicle.
• Valid Driver’s license; maintain minimum insurance liability on vehicle and complete motor vehicle driving record check.
• Accurate record keeping skills.
• Maintain Confidentiality.
• Attention to detail.
• Computer Acuity.
• Ability to be flexible and work in a fast-paced environment.

Physical Demands:

• Computer access.
• Ability to traverse homes, yards and stairways.
• Must be able to sit for periods of time at computer or while driving.

Work Environment:

• Traditional office environment along with meeting consumers at their homes or in public places.

The Nutrition Center Coordinator/Clerical Assistant is responsible for the day-to-day operation of on-site operations and activities and supervision of volunteers. Provides administrative functions related to the Agency’s Nutrition Program and back-up for the Nutrition Administrative Assistant.

Responsibilities:

• Takes daily meal counts from Nutrition meal sites over the phone and faxes to caterer to place daily food order in absence of the Nutrition Administrative Assistant.
• Covers receptionist duties as scheduled.
• Covers the Nutrition Program when other staff are out of the office.
• Enters all new volunteer information into Volunteer Program using Dbase III. Generates monthly report of all active volunteers for meal sites.
• Maintains work area in a neat and professional manner.
• Performs other miscellaneous duties and assignments, as directed by the Nutrition Director.
• Take reservations, order meals and supplies, monitor site meal waste daily.
• Maintain record keeping system including participant intakes, volunteer sign-in sheets, supply order forms and route sheets, volunteer registration forms and
• CORI forms.
• Submit routine paperwork and complete weekly, monthly and year-to-date reports, and time sheets for Site Managers and Sub Managers within specified time frames.
• Recruit, train, supervise, recognize and schedule volunteers and their duties.
• Oversees and performs kitchen duties required from time of receiving meals to serving of meals. This responsibility requires lifting up to 25 pounds.
• Supervise home delivered meals. Recruit and train drivers and arrange routes. Sign and verify volunteer mileage sheets monthly. Keep a list of driver substitutes and a schedule for MOW drivers posted. Check on Meals on Wheels clients. Implement emergency procedures when necessary.
• Assure safety and cleanliness of site, including washing hands and wearing gloves, hats and aprons.
• Report complaints, incidents, errors, discrepancies, or inadequacies of food service and disposables, including poor temperatures daily and equipment failures.
• Establish and train sufficient substitute site manager coverage and provide ongoing training.
• Be available to train new site managers or to substitute at another site.
• Attend staff meetings and accept supervision and training.
• Communicate effectively with elders and generate enthusiasm to promote site participation, volunteerism for community awareness of Tri-Valley.

Essential Functions/Qualifications:

• Regular and reliable attendance.
• Organizational and time management skills.
• Communication Skills with consumers, employees, physicians, family members, providers (telephone, email or in person, as needed).
• Meet deadlines in a timely fashion.
• Works as a member of a team.
• Accurate record keeping skills.
• Maintain Confidentiality.
• Attention to detail.
• General office procedures.
• Computer Acuity.
• Physical Demands:
• Computer access
• Must be able to sit for periods of time at computer.
• Must be able to carry or push items up to 25 pounds.

Work Environment:

• Driving, along with occasional delivery of meals, to consumers at their homes.

The basic function of the Residential Services Coordinator – Northbridge is to provide onsite services to housing residents.

Responsibilities:

• In collaboration with the staff of Northbridge, Uxbridge, Bellingham, Sutton, and Grafton Housing Authorities identify residents in need of services.
• Provide assessment, outreach, early and/or crisis intervention and advocacy to diverse resident population.
• Coordinate delivery of support services.
• Develop, implement and review comprehensive support service plans for residents,
• including connecting residents with needed in home supports.
• Work with Tri-Valley staff and other community agencies on behalf of residents.
• Collaborate with Housing Authority Directors to address the needs of residents at risk of eviction due to lease violations.
• Assist residents in changing/monitoring behaviors which, constitute lease violations to maintain tenancy, if possible.
• Provide counseling and support to residents concerning day-to-day adjustments.
• Provide on-going support for developing a cohesive sense of community by facilitating communication among residents.
• Coordinate educational/information programs at the developments.
• Provide technical assistance and education to housing staff concerning relevant elder and disability issues.
• Seeks appropriate housing arrangements for residents who require alternative housing.
• Complete monthly reports for DHCD.

Essential Functions/Qualifications:

• BA/BS Preferred; knowledge of housing/social services with elders or adults with disabilities preferred.
• Knowledge of Housing/Disability laws and regulations.
• Solid written, verbal, interpersonal and team skills.
• Regular and reliable attendance.
• Communicate with consumers, co-workers, family members, both face to face, email and/or telephonically.
• Computer acuity; Software including Word and Outlook.
• Motor Vehicle, valid driver’s license; maintain minimum insurance liability requirements and complete motor vehicle driving record check.
• Organizational and time management skills.
• Communication skills to include public speaking.
• Cultural competency and the ability to provide informed advocacy.
• Knowledge of home and community-based service systems and how to access and arrange services.
• MassHealth programs.
• Outreach and educational services.
• Public benefits.
• Written communication skills.
• Demonstrated analysis and problem-solving skills.
• Meet deadlines in a timely fashion.
• Able to develop and maintain positive effective relationships with providers, consumers, and the public.
• Works as a member of a team & independently.
• Maintain Confidentiality.
• Attention to detail.
• Consumer Advocate.
• Ability to be flexible and work in a fast-paced environment.
• Maintain caseload/production at program/department standards.
• Physical Demands:
• Computer access
• Ability to traverse homes, yards and stairways.
• Must be able to sit for periods of time at computer or while driving.
• Must be able to carry files of up to 5 pounds and laptop.

Work Environment:

• Traditional office environment along with meeting consumers at their homes or in public places

The basic function of the Clinical Assessment and Evaluation RN, (CAE RN) is to screen clients for Nursing Home, Adult Day Health, and 2176 Waiver eligibility. Assess clients for personal care. Provide nursing consultation to case managers, clients and providers of personal care.

 Responsibilities:

• Do on site assessments for Nursing Home (SNF), Adult Day Health (ADH) and 2176 Waiver screenings as needed in our service area.
• Assess clients for personal care and confer with Care Managers about the client’s total care plan.
• CAE RN will have the ability to determine medical eligibility for all CAE screenings: SNF, ADH, 2176 Waivers, Enhanced Community Options Program (ECOP), and Community Choices.
• Fill out the CDS RN 3 in SAMS to assess for personal care.
• Monitor and supervise the appropriateness, frequency and quality of personal care service via an annual visit.
• Attend meetings with providers, case conferences and be available for consultations as necessary.
• In conjunction with Care Managers, (CM), CAE RN determines client appropriateness for specific service options, promotes cost effective service substitutions, and establishes the frequency, scope and duration of services.
• Participates in assessment and interdisciplinary review of cases; consults with involved caregivers and documents findings.
• Advocate for HC clients with HMO’s, VNA’s and MD’s.
•  Provides consultation to providers and other community agencies.
• Maintains records and prepares reports as requested, including case summaries for Department of Medical Assistance hearings.
• The CAE RN is responsible for maintaining collaborative relationships among community agencies and institutions that service medical and social needs of clients.
• Perform, as needed, 2176 Waiver yearly re-determination via home visit or by contacting the CHHA or ADH for medical information.
• Discuss with Care Manager as requested to determine type of respite service the client requires. When necessary, do a home visit and assessment.
• Confers with Care Managers on all hospital discharged Personal Care (PC) clients. Makes home visits when necessary.
• Whenever the CAE RN or CM identifies a client in need of Certified Home Health Services (CHHS), the ASAP RN will make a home visit and complete the assessment form.
•  CAE RN meets and confers with CM, CM supervisor and RN supervisor to make recommendation regarding the needed CHHS services.
• CAE RN will document any conference the RN initiates with case manager on client’s journal notes (ICC).
• Maintain work area in a neat and professional manner.
• Perform any miscellaneous duties and assignments as directed by CAE nurse manager.

Essential Functions/Qualifications:

• Must have valid/current RN license in the state of Massachusetts.
• Must have minimum of one year of clinical experience.
• Regular and reliable attendance.
• Organizational and time management skills
• Communication Skills with consumers, physicians, family members, providers (telephone, email or in person, as needed) and employees.
• Communication Skills to include public speaking
• Communication skills with funders, state and federal agencies, ASAPs
• Cultural competency and the ability to provide informed advocacy
• Knowledge of home and community-based service systems and how to access and arrange services
• Program planning
• MassHealth programs
• Purchased services
• Knowledge and experience with long term care and social service delivery system; community resources
• Familiarity with state wide health care network
• Meet deadlines in a timely fashion
• Able to develop and maintain positive effective relationships with providers, consumers, and the public
• Problem solving skills
• Works as a member of a team and works independently
• Motor vehicle and Valid Driver’s license; maintain minimum insurance liability on vehicle and complete motor vehicle driving record check
• Accurate record keeping skills
• Maintain Confidentiality
• Attention to detail
• Computer Acuity
• Ability to be flexible and work in a fast-paced environment
• Maintain caseload/production at program/department standards

Physical Demands:

• Computer access
• Ability to traverse homes, yards and stairways.
• Must be able to sit for periods of time at computer or while driving.
• Must be able to carry files of up to 5 pounds and laptop.
• Frequent Standing and walking

Work Environment:

• Traditional office environment along with meeting consumers at their homes or in public places

The basic function of the Case Manager- Nursing Facility Liaison, (CTL) is to promote, educate, identify, and assist nursing home residents with options related to transitioning into the community.

Responsibilities:

• Onsite point of contact for residents, families, skilled nursing facility (SNF) staff and all other parties involved with resident’s care for nursing facility transitions to the community.
• Visit assigned nursing facilities weekly, collaborate with nursing and other SNF professionals and attend discharge meetings as needed.
• Meet with residents to increase awareness of community supports and services and introduce transition as a potential option.
• Have knowledge of and work closely with community partners of State programs to maximize resources and eligibility for services.
• Identifies individuals appropriate for the program based on resident’s desire to transition to community living environment including use of PASRR portal to facilitate resident identification.
• Assist residents to determine the most appropriate supportive program and determine eligibility to ensure effective transition to the community.
• Assist with gathering all necessary documentation needed and completion of applications for housing and other public benefits.
• Complete and follow up on program referrals to ensure timely transition.
• Develop a service plan and supportive networks through contact with consumer, formal and informal supports, and consultation with supervisor.
• Manage the discharge process along with purchasing goods and services for transition.
• Assist and provide support to families and consumers.  Encourage self-advocacy.
• Maintain regular communication with supervisor and nursing staff for expedited clinical screenings and care planning to support community planning and transition.
• Participate in monthly program meetings.
• Complete monthly reports, accurately and on time.

Essential Functions/Qualifications:

• Bachelor’s degree in Social Work, Human Services or related field, preferred.
• Experience and/or strong interest in the field of human services via previous employment, internship, volunteer activity and/or additional studies.
• Regular and reliable attendance.
• Valid driver’s license and/or reliable transportation; insurance verification and motor vehicle record check.
• Organizational and time management skills.
• Communication Skills with employees, consumers, physicians, state and federal agencies, family members, providers (telephone, email or in person, as needed).
• Cultural competency and the ability to provide informed advocacy.
• Knowledge of home and community-based service systems and how to access and arrange services, MassHealth programs and public benefits (preferred).
• Have a high level of organization, maintain documentation standards, tracking and delivery of support to residents.
• Familiarity with state-wide health care network (preferred).
• Written communication skills.
• Demonstrated analysis and problem-solving skills.
• Able to develop and maintain positive effective relationships with providers, consumers, and the public.
• Works as a member of a team and independently.
• Maintain Confidentiality.
• Attention to detail.
• Computer acuity: software: Windows, Excel, Power Point, Outlook.
• Ability to be flexible and work in a fast-paced environment.
• Maintain caseload/production at program/department standards.

Physical Demands:

• Computer access.
• Ability to traverse homes, yards and stairways.
• Must be able to sit for periods of time at a computer or while driving.
• Must be able to carry files of up to 5 pounds and laptop.
• Occasional bending, reaching, twisting, standing and climbing.
• Frequent Standing and walking.

Work Environment:

Traditional office environment including work from home along with meeting consumers at their homes or in public places.

The basic function of the Protective Services Worker is to determine the need for protective intervention and the delivery or arrangement of services to abused elders in accordance with EOEA regulations 651 CMR 5.00.

Responsibilities:

• Receives reports of abuse of people 60 years or older.

• Determines whether reasonable cause to believe that a reportable condition exists.

• Determines whether an emergency situation exists and responds accordingly (see CMR 5.00 Section 5.04).

• Conducts an assessment of the abused elderly person to include the evaluation of the functional capacity situation and resources available to the person within required timeframe. Assessments may be conducted in the elder’s home, nursing facility or other setting.

• Develops a protective service treatment plan, and when necessary, arranges for a geriatric evaluation.

• When necessary, petitions the Court for a protective order pursuant to Section 20(A) of the Act.

• Refers determination of serious abuse to the District Attorney of the County within 48 hours and the Executive Office of Elder Affairs.

• Completes necessary forms and documentation in compliance with the program.

• Maintains work area in a neat and professional manner.

• Provide support to staff with maintaining records, making collateral contacts and providing emergency visits to assess the needs of the elder.

• Performs miscellaneous duties and assignments as directed by immediate supervisor.

Essential Functions/Qualifications:

• Regular and reliable attendance.

• Bachelors’ degree from an accredited school in social work, psychology, counseling, human development, nursing, sociology, criminal justice, public health, public policy, gerontology or related field.

• Minimum of two years of experience in counseling, casework or case management providing protective or crisis intervention services.

• Organizational and time management skills.

• Communication Skills with employees, consumers, physicians, family members, providers (telephone, email or in person, as needed).

• Written communication skills.

• Demonstrated analysis and problem-solving skills.

• Meet deadlines in a timely fashion.

• Able to develop and maintain positive effective relationships with providers, consumers, and the public.

• Problem solving skills.

• Works as a member of a team and independently.

• Motor vehicle and Valid Driver’s license; maintain minimum insurance liability on vehicle and complete motor vehicle driving record check.

• Accurate record keeping skills.

• Maintain Confidentiality.

• Attention to detail.

• Computer Acuity.

• Ability to be flexible and work in a fast-paced environment.

• Maintain caseload/production at program/department standards.

Physical Demands:

• Computer access.

• Ability to traverse homes, yards and stairways.

• Must be able to sit for periods of time at computer or while driving.

• Must be able to carry files of up to 5 pounds and laptop.

Work Environment:

• Traditional office environment along with meeting consumers at their homes or in public places.

The basic function of the Benefits Facilitator is to assist older adults in completing applications and accessing public benefits.

Roles/Responsibilities:

• Support Hospital to Home Options Counselor and Tri-Valley staff by providing Milford Hospital Patients and Tri-Valley consumers with education about public benefits and assist with public benefits applications.
• Encourage self- advocacy for those who seek assistance and support.
• Follow the principles of consumer directed care.
• Meet with consumers at Milford Hospital, a host site, community setting, at their home, or virtually and provide assistance with the application process as needed.
• Assist with annual redetermination paperwork for benefits as consumer needs.
• Provide a 30 day follow up call or home visit to ensure that consumer has accessed chosen benefits.
• Attends interdisciplinary meetings with appropriate Agency staff regarding the status of the applications and outcomes. Document activities regarding counseling sessions, progress notes, and correspondence in a prescribed format.
• Completes training identified by Supervisor which enhances the Benefit Enrollment Facilitator’s knowledge and skills, including training as a Certified Application Counselor with MassHealth.
• Gather statistical data monthly. Examine statistics and make recommendations where outreach activities should be focused. Participate in staff meetings; attend training and orientation sessions as assigned.
• Maintain work area in a neat and professional manner. Meet with supervisor on regular basis.
• Perform miscellaneous duties and assignments as directed by immediate supervisor.

Essential Functions/Qualifications:

• Bachelor’s degree in human services, Community Health, Social Work or related field preferred.
• Regular and reliable attendance.
• Must be able to communicate effectively telephonically and face to face.
• Requires excellent written and verbal communication skills.
• Computer acuity.
• Ability to be flexible and work in a fast-paced environment.
• Ability to work constructively as a team member.
• Current driver’s license, reliable transportation, willingness to travel throughout Central Massachusetts, meet DVR and liability insurance requirements.
• Ability to organize and plan work effectively.
• Knowledge and experience with the long-term care and social service delivery systems, community resources and the local service systems for older adults and persons with disabilities.
• Knowledge and experience preferred with: Low Income Home Energy Assistance Program (LIHEAP), Medicaid, Supplemental Nutrition Assistance Program (SNAP benefits), Medicare Part D Extra Help- Low Income Subsidy (LIS), Medicare Saving Program (MSP).

Work Environment:

• Office environment; community settings including regional hospital and senior centers.
• May need to drive to and from various locations.

The basic function of the Supportive Housing Coordinator is to provide coordination of services and support to all residents living in Milford at Fairfield Court, Birmingham Court, Greenleaf Terrace and in Mendon at Sunrise Apartments. Coordinator is based in the community and comes into the Tri-Valley office in Dudley only a couple of times a month.

Responsibilities:

• Schedule office hours at the Supportive Housing site to provide easy access to residents and Housing Authority Management. The coordinator’s office is in Milford next to the community room at Birmingham Court.
• In collaboration with the housing authority staff identifies residents in need of services.
• Accept referrals from housing management and/or designated staff for elderly residents and/or residents with disabilities.
• Inform and refer residents to publicly funded programs (GAFC, ECOP and Home Care, food stamps, Veteran’s benefits, etc…) and assist residents with securing benefits as appropriate.
• Identify gaps in services to residents. Develop, implement and offer a range of services and programs to residents with the goals of establishing and maintaining cost effectiveness and affordable services, and addressing unmet needs. Including assisting residents who do not qualify for state programs to access private pay options.
• Coordinate delivery of support services. Including working closely with Tri-Valley nutrition program and HM vendor around the functioning of the congregate meal site for all residents.
• Maintain contact with Tri-Valley, Inc. Nurse and CM (if Coordinator is not also the CM) to provide ongoing monitoring of residents’ needs and services.
• Maintain close communication with vendor staff to ensure proper and timely documentation and coordination of services, billing and consumer issues.
• Meet regularly with residents to address social, recreational and educational needs and address barriers to participation with the goal of developing a cohesive sense of community in the complex by facilitating communication among residents.
• Coordinate educational/informational/social programs at the site.
• Work closely with community organizations and social service providers to provide programs, support and services to allow residents to age in place.
• Provide outreach, advocacy, and crisis intervention to residents accordingly.
• Collaborate with the housing authority director to address the needs of residents at risk of eviction due to lease violations.
• Provide outreach to perspective residents and their families around the assisted living model of the site.
• Provide information and referral services to residents in need of housing alternatives.
• Provide accurate and timely documentation to meet all contractual and administrative standards as required by Tri-Valley, Inc. and Housing Authority, including a quarterly report to the Housing Authority regarding programs/activities, participation numbers, and other pertinent information.
• Maintain secure consumer records for all tenants receiving services.
• Coordinate and chair monthly Supportive Housing Team meetings.
• Attend monthly State Home Care staff meetings at Tri-Valley.
• Meet with Supervisor on a regular basis.
• Other duties as assigned.

Essential Functions/Qualifications:

• BA/BS Degree preferred; knowledge of housing/social services with elders or adults with disabilities strongly preferred.
• Knowledge of Housing/Disability laws and regulations helpful.
• Solid written, verbal, interpersonal and team skills.
• Regular and reliable attendance.
• Communicate with consumers, co-workers, family members, both face to face, email and/or telephonically.
• Computer acuity.
• Valid driver’s license; maintain minimum insurance liability requirements and complete motor vehicle driving record check.
• Organizational and time management skills.
• Communication Skills to include public speaking.
• Cultural competency and the ability to provide informed advocacy.
• Knowledge of home and community-based service systems and how to access and arrange services.
• MassHealth programs.
• Outreach and educational services.
• Public benefits.
• Written communication skills.
• Demonstrated analysis and problem solving skills.
• Meet deadlines in a timely fashion.
• Knowledge of housing and disability laws and regulations.
• Able to develop and maintain positive effective relationships with providers, consumers, and the public.
• Works as a member of a team.
• Works independently.
• Motor vehicle.
• Maintain Confidentiality.
• Attention to detail.
• Consumer Advocate.
• Software including Word Outlook.
• Ability to be flexible and work in a fast-paced environment.
• Maintain caseload/production at program/department standards.
•  

Physical Demands:

• Computer access.
• Ability to traverse homes, yards and stairways.
• Must be able to sit for periods of time at computer or while driving.
• Must be able to carry files of up to 5 pounds and laptop.

Work Environment:

• Traditional office environment along with meeting consumers at their homes or in public places.

The Personal Care Attendant program (PCA) is designed to help people of any age with chronic illnesses or permanent disabilities and need assistance with personal care tasks who are living in a home environment. Per diem RNs are needed to conduct assessments for the PCA program. MassHealth requires standard documentation and complete assessments for all people applying for services. The assessment itself takes approximately one hour to conduct. The Tri-Valley, Inc. service area includes 29 towns in the Worcester County and Milford area.  Driver’s license, motor vehicle record check and minimum insurance requirements.

Responsibilities:

• Be knowledgeable of and comply with all state, federal and agency regulations, policies and procedures pertaining to the PCM program including time frames and Tri-Valley’s agency mission.
• Assess the consumer’s physical and cognitive condition and resulting functional limitations to determine the consumer’s personal care assistance services.   
• Determine the type and amount of personal care assistance required by the potential and existing participants according to state guidelines through face-to-face interviews.  Review fully with consumer before finalizing request for services.        
• Follow the schedule for re-evaluations to ensure timeliness and continuity of PCA services.
• Provide timely and complete written documentation of evaluations and re-evaluations requests.
• Refer consumers to appropriate medical providers or other community resources when necessary.
• Perform other duties as assigned.

Essential Functions/Qualifications:

•  Licensed as a registered nurse by the Massachusetts Board of Registration in Nursing and in good standing with the Board.
• Organizational and time management skills.
• Communication Skills with consumers, employees, physicians, family members, providers (telephone, email or in person, as needed).
• Cultural competency and the ability to provide informed advocacy.
• Arithmetic computations.
• Medical terminology.
• Written communication skills.
• Demonstrated analysis and problem-solving skills.
• Meet deadlines in a timely fashion.
• Works independently.
• Motor vehicle.
• Valid Driver’s license; maintain minimum insurance liability on vehicle and complete motor vehicle driving record check.
• Maintain Confidentiality.
• Attention to detail.
• Knowledge of PCA program and or MassHealth programs and community supports.
• Computer Acuity
• Software Windows, excel, power point, Dynamics, Outlook.
• Calculators

 Physical Demands:

•  Computer access
• Ability to traverse homes, yards and stairways.
• Must be able to sit for periods of time at computer or while driving.

 Work Environment:

• Driving to consumers at their homes.

The basic function of the Occupational Therapist for the Personal Care Attendant, (OT PCA) Program is to participate in screening potential participants in their homes or other settings.

Responsibilities:

• Be knowledgeable of and comply with all state, federal and agency regulations, policies and procedures pertaining to the PCM program including time frames and Tri-Valley’s agency mission.
• Assess the consumer’s physical and cognitive condition and resulting functional limitations to determine the consumer’s personal care assistance services.   
• Determine the type and level of personal care assistance required by the potential participant according to state guidelines through face-to-face interviews.  Review fully with consumer.
• Provide timely and complete written documentation of evaluation requests.
• Refer consumers to appropriate medical providers or other community resources when necessary.
• Perform other duties as assigned.

Essential Functions/Qualifications:

• Licensed by the Massachusetts Division of Registration in Allied Health Professions and in good standing with the Division of Registration; and currently certified by the National Board of Certification in Occupational Therapy and in good standing with the Board.
• Regular and reliable attendance.
• Organizational and time management skills.
• Communication Skills with consumers, physicians, family members, providers (telephone, email or in person, as needed).
• Communication Skills to include public speaking.
• Communication skills with funders, state and federal agencies, ASAPs.
• Communications skills with employees.
• Cultural competency and the ability to provide informed advocacy.
• Medical terminology.
• Written communication skills.
• Demonstrated analysis and problem-solving skills.
• Meets deadlines in a timely fashion.
• Works independently.
• Motor vehicle.
• Valid Driver’s license; maintain minimum insurance liability on vehicle and complete motor vehicle driving record check.
• Maintain Confidentiality.
• Attention to detail.
• Knowledge of PCA program and or MassHealth programs and community supports.
• Computer Acuity.
• Software Windows, Excel, Power Point, Dynamics, Outlook.
• Calculators.

Physical Demands:

• Computer access
• Ability to traverse homes, yards and stairways.
• Must be able to sit for periods of time at computer or while driving.

 Work Environment:

• Driving to consumers at their homes

The basic function of the Licensed Practical Nurse, (LPN) in the Personal Care Attendant, (PCA) program is to participate in screening existing program participants in their homes or other settings. 

Responsibilities:

• Be knowledgeable of and comply with all state, federal and agency regulations, policies and procedures pertaining to the PCM program including time frames and Tri-Valley’s agency mission.
• Assess the consumer’s physical and cognitive condition and resulting functional limitations to determine the consumer’s personal care assistance services.
• Determine the type and amount of personal care assistance required by the existing participants according to state guidelines through face-to-face interviews. Review fully with consumer before finalizing request for services.               
• Follow the schedule for re-evaluations to insure timeliness and continuity of PCA services.
• Provide timely and complete written documentation of re-evaluation requests.
• Refer consumers to appropriate medical providers or other community resources when necessary.
• Perform other duties as assigned.

Essential Functions/Qualifications:

• Licensed as a practical nurse by the Massachusetts Board of Registration in Nursing and in good standing with the Board.
• Communicates well with clients, co-workers, etc.
• Adheres to HIPPA protocols regarding confidentiality.
• Experience in Microsoft Word, Microsoft Excel, and Microsoft Outlook.

The basic function of the Clinical Assessment and Evaluation RN, (CAE RN) is to screen clients for Nursing Home, Adult Day Health, and 2176 Waiver eligibility. Assess clients for personal care. Provide nursing consultation to case managers, clients and providers of personal care.

 Responsibilities:

• Do on site assessments for Nursing Home (SNF), Adult Day Health (ADH) and 2176 Waiver screenings as needed in our service area.
• Assess clients for personal care and confer with Care Managers about the client’s total care plan.
• CAE RN will have the ability to determine medical eligibility for all CAE screenings: SNF, ADH, 2176 Waivers, Enhanced Community Options Program (ECOP), and Community Choices.
• Fill out the CDS RN 3 in SAMS to assess for personal care.
• Monitor and supervise the appropriateness, frequency and quality of personal care service via an annual visit.
• Attend meetings with providers, case conferences and be available for consultations as necessary.
• In conjunction with Care Managers, (CM), CAE RN determines client appropriateness for specific service options, promotes cost effective service substitutions, and establishes the frequency, scope and duration of services.
• Participates in assessment and interdisciplinary review of cases; consults with involved caregivers and documents findings.
• Advocate for HC clients with HMO’s, VNA’s and MD’s.
•  Provides consultation to providers and other community agencies.
• Maintains records and prepares reports as requested, including case summaries for Department of Medical Assistance hearings.
• The CAE RN is responsible for maintaining collaborative relationships among community agencies and institutions that service medical and social needs of clients.
• Perform, as needed, 2176 Waiver yearly re-determination via home visit or by contacting the CHHA or ADH for medical information.
• Discuss with Care Manager as requested to determine type of respite service the client requires. When necessary, do a home visit and assessment.
• Confers with Care Managers on all hospital discharged Personal Care (PC) clients. Makes home visits when necessary.
• Whenever the CAE RN or CM identifies a client in need of Certified Home Health Services (CHHS), the ASAP RN will make a home visit and complete the assessment form.
• In home visits are required.
• CAE RN meets and confers with CM, CM supervisor and RN supervisor to make recommendation regarding the needed CHHS services.
• CAE RN will document any conference the RN initiates with case manager on client’s journal notes (ICC).
• Maintain work area in a neat and professional manner.
• Perform any miscellaneous duties and assignments as directed by CAE nurse manager.

Essential Functions/Qualifications:

• Must have valid/current RN license in the state of Massachusetts.
• Must have minimum of one year of clinical experience.
• Regular and reliable attendance.
• Organizational and time management skills
• Communication Skills with consumers, physicians, family members, providers (telephone, email or in person, as needed) and employees.
• Communication Skills to include public speaking
• Communication skills with funders, state and federal agencies, ASAPs
• Cultural competency and the ability to provide informed advocacy
• Knowledge of home and community-based service systems and how to access and arrange services
• Program planning
• MassHealth programs
• Purchased services
• Knowledge and experience with long term care and social service delivery system; community resources
• Familiarity with state wide health care network
• Meet deadlines in a timely fashion
• Able to develop and maintain positive effective relationships with providers, consumers, and the public
• Problem solving skills
• Works as a member of a team and works independently
• Motor vehicle and Valid Driver’s license; maintain minimum insurance liability on vehicle and complete motor vehicle driving record check
• Accurate record keeping skills
• Maintain Confidentiality
• Attention to detail
• Computer Acuity
• Ability to be flexible and work in a fast-paced environment
• Maintain caseload/production at program/department standards

Physical Demands:

• Computer access
• Ability to traverse homes, yards and stairways.
• Must be able to sit for periods of time at computer or while driving.
• Must be able to carry files of up to 5 pounds and laptop.
• Frequent Standing and walking

Work Environment:

• Traditional office environment along with meeting consumers at their homes or in public places

To learn more about volunteering with Tri-Valley please visit the Volunteer Page.