Job Title: Nursing Home Transition (NHT) Coordinator

PCC Philosophy

Patient Care Coordination, Inc. (“PCC”) is committed to enhancing the quality of life of our consumers by providing a well-rounded, focused and consumer-approached level of service. Our consumer-approached focus enables Patient Care Coordination to provide consumers with the proper and most appropriate types of services to enable independence in the community.

Job Description
Patient Care Coordination, Inc. (PCC) supports the Consumers to independence by promoting individualized quality relationship and maintaining community partnerships. PCC NHT program advocates for the Consumers and helps determine their individualized needs in receiving the appropriate support to transition from the nursing facility back into the community setting. PCC adheres to all state and federal mandated processes and regulations along with all contractual obligations set forth by the contracted Health Plans/ Managed Care Organizations.

The goals of the Nursing Home Transition program are as follows:

1. Help rebalance the long-term living system in Pennsylvania so that people have a choice of where they live and receive services.

2. Enhance opportunities for individuals to move to the community by identifying individuals who wish to return to the community.

3. Identify and overcome barriers that prevent transitions.

4. Empower individuals so they are involved to the extent possible in planning and directing their own transition from a nursing facility back to a home of their choice in the community.

5. Develop the necessary infrastructure and supports in the community.

6. Expand and strengthen collaboration between aging and disability organizations to provide support and expertise to the NHT Program.

7. Educate individuals and families about long-term living services.

Job Responsibilities for Nursing Home Transition (NHT) Coordinator

1. Provide case management and support to Consumers currently residing within a nursing facility and choosing to transition back into the community.

2. Travel to local nursing homes; conduct intake, assessment interviews, identify community needs, and assist with housing needs.

3. Collaborate with nursing home social work staff, providers, vendors, family, Health plan NHT team and other SCEs to facilitate a successful transition.

4. Assist consumers and their families with the identification of services and supports available in the community.

5. Educate consumers and families about HCBS Waivers and available service.

6. Provide assistance in consumer obtaining waiver eligibility and maintain ongoing communication with CAO and MCO to ensure appropriate waiver activation.

7. Maintain a personal/family transition plan, specifically related and tailored to the Consumer.

8. Assist Consumers in addressing methods to manage any factors related to significant health issues including behavioral health needs, safety issues, financial concerns, any ongoing medical and/or community support needs.

9. Enable Consumers/family to maintain the autonomy to make decisions based on self-setting goals and desired outcomes.

10. Identify risk factors that the consumer’s choices may present and assist them in developing strategies to mitigate those potential risks.

11. Coordinate NHT related services and supports to transition the Consumer into the community while collaborating with local housing authorities, Regional Housing Coordinators (RHC), county mental health and other allied community agencies.

12. Assist with establishing proper housing for the Consumers, including but not limited to, housing applications, housing vouchers, housing research, home adaptations, gathering housing documentation, etc.)

13. Provide Consumer transition services which may include, but not limited to:

• Secure community based housing
• Applying for a housing voucher
• Consumer’s transitional move into new home
• Coordinate setting up the Consumer’s household.
• Assist with home modifications, as needed.
• Provide home and community based support.
• Coordinate Nursing Facility collaborations, skills training, and support for formal and informal personal care givers.
• Ensuring that care givers, family members or friends have adequate support such as;
• Training
• Supplies
• Assistance with required forms and procedures
• Advice and Information
• Encouragement

14. Identification of funds to establish the consumer’s basic living arrangement to be used for:

• Security deposits to obtain a lease on a living unit
• Household items
• Utilities
• Telephone service
• Electric and/or gas heating
• Adaptive equipment
• Assistance with learning how to manage a household budget
• Other set up fees, additional fees and/or deposits, as needed.

15. Identification of essential household furnishings (i.e., Bed, bedding, dining table and chairs, eating utensils and food preparation items, etc.)

16. Identifies and maximizes use of third-party payers.

17. Implement and monitor the NHT ISP consistent with timeframes and requirements of the waiver.

18. Coordinate services with formal and informal supports and other community resources to assure a successful transition.

19. Document and justify the purchase of services and products and attempt to obtain or purchase through alternative resources from the State.

20. In addition, document and justify the purchase of services and products to the other Service Coordination Agencies(i.e. furniture, home security deposits).

21. Facilitate and advocate for Consumer choice of providers.

22. Arrange for needed services and works cooperatively with consumer, family members, as well as other service providers.

23. Submits all necessary forms, data entry, case management information, written reports and notes as required for the Consumer’s case record/binder.

24. Complete necessary data per internal standards and maintain automated programs.

25. Maintains and exceeds daily, weekly, and monthly billing requirements per the billable unit (if applicable) standards currently established.

26. Train NHT coordinators, discharge planners, nursing facility staff, and involved interdisciplinary team about the
NHT effort to secure their cooperation.

27. Participates in orientation and training and in-service trainings as assigned and attends regularly scheduled supervision and staff meetings.

28. Participate State specific and PCC training series (i.e., acronyms, proper transfer techniques, standard precautions, communicable diseases, avoiding injuries at work, disability-related trainings).

29. Monitors consumer satisfaction to ensure quality of services provided.
30. Informs Consumers of their rights and assists with the complaint, grievance, and DHS Fair Hearing.
31. Report abuse, neglect, exploitation, or other inappropriate activity to internal and external parties per federal, and

State guidelines.
32. Maintains ongoing partnership and communication with MCO’s Nursing Home Transition team.
33. Other duties as needed.

Qualifications

• Bachelor's degree in sociology, social welfare, psychology, gerontology or another behavioral science required
• Experience in Nursing Home Transition preferred, but not required
• 3 or more years experience in a related field
• Proficient experience with databases and Microsoft Office Suite required
• Communication and customer service skills are essential
• Ability to organize multiple tasks in a timely manner
• Travel throughout Philadelphia and/or surrounding counties is required up to 50% per week
• Must have valid Driver’s license and personal vehicle
• Multilingual a plus

Job Type: Full-time

Pay: $38,000.00 - $41,000.00 per year

Benefits:

• 401(k) matching
• Dental insurance
• Employee assistance program
• Health insurance
• Life insurance
• Paid time off
• Vision insurance

Schedule:

• 8 hour shift
• Monday to Friday

Ability to commute/relocate:

• Philadelphia, PA 19123: Reliably commute or planning to relocate before starting work (Required)

Application Question(s):

• Do you have experience in Nursing Home Transitions?

Experience:

• Case management: 1 year (Preferred)

Work Location: Hybrid remote in Philadelphia, PA 19123