• Community resource referral and management
• Collaboration with participant, families, and interdisciplinary team
• Providing education

• Conducts home visits according to participant need.
• Provides emotional support and assistance to Senior Care Partners P.A.C.E. participants in maintaining their independence for as long as possible.
• Administers assessments as needed.
• Administers screening tools without interpretation.
• Schedules family meetings and facilitates when needed.
• Functions as a member of the Interdisciplinary Team (IDT) with close collaboration with the behavioral health team.
• Communicates participant changes to team members, participates in IDT meetings, and the development of participant plan of care.
• Offer opportunities to discuss healthcare wishes and complete Advanced Directives for Healthcare.
• Refers participants to appropriate community resources and assists with referrals as needed.
• Provides education and support to participant caregivers and family members.
• Assists with coordination of respite placement for caregiver burden.
• Communicates with community partners around participant care needs.
• Provides crisis intervention to participants as needed.
• May provide supervision of BSW students if within scope.
• Must complete all required education and file requirements on time.
• Must care, support, and collaborate with everyone involved in the participant’s care including staff and the participant’s family using the participant centered care model.
• Documents in the participant’s medical record as required by policy.
• Participates in Quality Improvement activities as needed.
• Keeps the leader informed of problems or issues.
• Performs other duties as assigned.

• BSW, licensed in the state of Michigan.
• Minimum of one year of experience working with the frail, elderly, or long-term care population.
• Case management experience required.
• Ability to collaborate effectively with other IDT members.
• Detail oriented with good problem-solving skills.
• Strong communication skills, both written and verbal.
• Self-starter with excellent critical thinking skills.
• Well-developed ability to show discretion and maintain confidentiality.
• Excellent organizational skills.
• Proficiency with MS Office Suite, Word, Outlook, PowerPoint & Excel.

• Possess current CPR certification by AHA or willing and able to obtain as offered by Senior Care Partners P.A.C.E.
• Possess current MoCA certification or willing and able to obtain as offered by Senior Care Partners P.A.C.E. within 90 days of employment.
• Demonstrate our core values of compassion, integrity, teamwork, and excellence.
• Champion of Senior Care Partners P.A.C.E. philosophy.
• Must provide exceptional customer service in support of all staff, external partners, and participants.
• Must possess the ability to make independent decisions when circumstances warrant such action.
• Must possess the ability to plan, organize, develop, implement, and interpret programs, goals, objectives, policies, and procedures.

• Has a visible presence while working in the center and is subject to frequent interruptions.
• Communicates with staff, participants, caregivers, and other organizations as necessary.
• Works beyond normal working hours and on weekends and holidays as necessary.
• Subject to callback during emergency conditions (e.g., severe weather, evacuation, disaster, etc.).
• May be subject to exposure to TB, AIDS, and/or Hepatitis B virus.
• May work in an unpredictable home environment with variations in cleanliness, temperature, behaviors, smoke, animals, and other potential hazards.
• Required to drive a car in all types of weather.

Physical Demands (With or without accommodations)

• Must be able to cope with the mental and emotional stress of the position.
• Must function independently, and have flexibility, personal integrity, and the ability to work effectively with participants, personnel, and support agencies.
• Must be able to push, pull, move, sit, or stand for long periods of time.
• Lift up to 20 pounds as needed.

• Must have reliable transportation, current valid Michigan driver’s license and car insurance.
• Must be 18 years of age or older.
• Must be fully vaccinated, or willing to be fully vaccinated against the following communicable diseases: Influenza, MMR, Varicella, Tdap/Td, Covid-19, and Hepatitis B.