Community Living Specialist – Nursing Home Relocation

Responsible for responding to requests from a variety of sources for information and assistance on behalf of individuals residing in nursing homes. The information provided will inform those who are elderly and/or disabled or their caregivers about options available to support them in the community as an alternative to nursing home care. Assist those who are interested by helping to remove obstacles to successful relocations. Provide short term case management to those who have financial resources but lack the supports necessary to coordinate supports. Perform eligibility screens for those seeking public funding and make appropriate referrals for financial eligibility determination and enrollment choices for those who are eligible. Performs other duties as required.

ESSENTIAL FUNCTIONS:

1. Identifies and connects with residents of nursing homes who may be interested in relocating to the community.

2. Develops working relationships with key nursing home staff to understand the role of this position, how to identify those who are interested in hearing more about relocating to the community and when to make referrals.

3. Provides education to nursing home residents, their caregivers and others in the community about community living alternatives and options for addressing health and safety in community-based settings including publicly funded options.

4. Provides individual options counseling to residents interested in relocating and their families/decision makers who want to know specific information as it relates to their personal situation.

5. Provides short-term case management for those who have no one able or willing to help coordinate services or supports.

6. Advocates on behalf of residents who encounter barriers to relocation and collaborates with families, decision makers, discharge planners, physicians, ombudsman, advocates and others to review ways to overcome them.

7. Conducts the Adult Long-Term Care Functional to determine eligibility and make referrals for financial eligibility determination to economic support for those seeking public funding.

8. Conducts enrollment counseling for those who meet eligibility for public funding and make appropriate referrals once a choice has been made to the appropriate agency.

10. Provides consultation to care managers, MCOs and IRIS consultants relative to the removal of barriers to the person’s success in the community.

11. Responds to all referrals made to the ADRC from a variety of individuals and community partners regarding those who reside in nursing homes.

12. Responds to MDS Section Q referrals within required time frames and provides options counseling and any other service that may be necessary. Works with nursing homes in understanding the purpose and requirements of these referrals.

13. Collaborates with hospital discharge planners to inform individuals and their decision makers about options available in the community and, with permission, to make referrals when a person has been discharged to a nursing home.

14. Follows up with people after discharge to the community to see how they are managing and whether there is additional information or assistance that would be helpful.

15. Submits reports of monthly activities performed, as assigned.

16. Completes required documentation as required for case management activities, functional screens, Money Follows the Person, and others as required.

JOB QUALIFICATIONS:

1. Bachelors degree in human services or related field.

2. Extensive knowledge of the long-term care needs of elders and people with disabilities.

3. Extensive knowledge of home and community-based services.

4. Personal vehicle required and an ability to drive and travel in order to make regular visits to nursing homes in assigned geographic region and to statewide/regional meetings. Must possess a valid driver’s license and maintain adequate auto insurance for job-related travel within Wisconsin.