About West Side Federation for Senior and Supportive Housing (WSFSSH)
The West Side Federation for Senior and Supportive Housing, Inc. (WSFSSH) is a community‐based organization whose mission is to provide safe, affordable housing with supportive services within a residential setting which enhances the independence and dignity of each person. WSFSSH develops and manages housing and provides social services for low‐income older persons, many of whom live with mental illness and/or have experienced homelessness. Our 440 staff members serve more than 2600 residents in 30 buildings located throughout Manhattan and the Bronx.
About WSFSSH’s Wellness Initiative
WSFSSH’s Wellness Initiative seeks to create a culture of wellness within our residential developments for older adults to facilitate the adoption of healthy habits that will improve their overall physical, emotional, and mental well-being. We aim to identify, develop and implement best practices to improve health outcomes for older adults, including and particularly for those with histories of homelessness, mental illness and/or substance abuse. An overarching goal of the initiative is to increase our resident connections to high quality primary and preventive health care so as to encourage better resident health management and quality of life through reduced emergency room visits and hospitalizations. The initiative will focus on utilizing appropriate primary and preventive medical care, managing chronic conditions (including medication management), and expanding resident knowledge of healthy habits such as increasing physical activity and consuming more nutritional food.
The Wellness Coordinator report to the Director of Clinical and Social Services and is responsible for the overall coordination of residents’ health-related services at the site level. The Coordinator must be capable of comprehending complex public health issues and have the ability to develop programs and strategies to engage residents in taking a more proactive approach to their health. The Coordinator builds relationships with the residents and their care team (physicians, nurses, social workers, etc.) to coordinate and ensure the provision of health-related services. The Coordinator assists the residents and their social workers with navigating health-related systems, access issues, and service coordination. The Coordinator acts as a liaison to external health agencies and serves as a conduit for the transmission of health information between WSFSSH’s social work team and the health care providers.
Note: This position is funded by a 2- year grant. Continued employment in this role may be contingent upon receipt of additional grant funding. Candidates with appropriate credentials may have the opportunity to transfer to other roles within WSFSSH upon conclusion of the grant term.
Essential Duties and Responsibilities
- Build collaborative partnerships with third party health and wellness providers, including but not limited to the on-site Federally Qualified Health Center (FQHC), area hospitals, physicians and medical practices, pharmacies, and PACE providers to focus on coordination of care, sharing of care information, and co-creation of programs focused on the health and wellness of residents
- Give specific focus to programs and focus groups for seniors with high-need (high cost) health conditions (e.g. diabetes management, falls prevention, weight control, high blood pressure control, etc.)
- Work with the residents and residents’ social workers to complete initial and ongoing health screens and surveys aimed at identifying the residents’ physical, emotional, and mental health needs and to develop plans of care that are comprehensive in meeting those needs.
- Coordinate all documentation and data entry associated with the wellness initiative
- Track resident enrollment with Medicaid Managed Long Term Care Organizations (MCOs)
- Obtain resident consents to share health related data
- Verify that resident Electronic Medical Records are updated after each health care visit and share updated health dashboards with residents’ social workers
- Collaborate with staff within WSFSSH’s data department to regularly monitor and analyze resident health-related data and to assess program performance at both an aggregate and individualized level – with the goal of continuously identifying barriers to quality care to refine best practices
- Compile data and generate program updates for internal and external stakeholders, including grant funders, WSFSSH leadership, and WSFSSH’s on-site care teams
Health Care Coordination
- Initiate and maintain relationships with the resident/resident’s social worker and the third parties providing health-related services to the resident (e.g. physicians, hospitals, health clinics, limited licensed home care agencies, PACE providers, etc.)
- Specifically build a strong relationship with the on-site (FQHC) to actively refer residents for primary (and specialty) care
- Schedule resident medical appointments and assist residents in attending their appointments, including facilitating transport
- Provide post-appointment coordination as appropriate (e.g. obtaining prescriptions, scheduling follow-ups)
- Troubleshoot maintenance of residents’ health related entitlements, including Medicare, Medicaid, and personal care assistance provided by Limited Licensed Home Care Agencies under contract with MCOs
Care Plan Communication
- Participate in regular team meetings with WSFSSH on-site wellness staff (nurse, social workers and medication management staff) to review resident care plans
- Provide regular communication to on-site staff regarding resident-specific wellness updates
- Plan, lead and implement health-related group activities and events for residents, including and in particular activities sponsored by the on-site FQHC
- Plan and conduct resident outreach to encourage participation in wellness activities
- Develop and lead focus groups with residents who have high-need (high-cost) health conditions (e.g. diabetes management, falls prevention, weight control, high blood pressure, etc.)
- Familiar with health issues and concerns prevalent in underserved communities of color
- Masters degree, or experiential equivalent, in Human Services, Public Health, Social Work, or a related area
- Proven knowledge of health-related community resources, including a clear understanding of health-related benefits and entitlements, as demonstrated by a minimum of 2 years of job-related experience
- Prior experience providing case management &/or medical focused care coordination services to individuals with chronic medical conditions is strongly preferred
- Bilingual Spanish speaking preferred
- Prior experience working with older adults preferred
- Strong oral and written communication skills, including the ability to effectively present information and respond to questions from internal/external sources
Commensurate with experience.
Equal Opportunity Employer
WSFSSH is committed to principles of Diversity, Inclusion & Equity. Individuals with life experiences as a person of color; being LGBTQIA+; having a disability; &/or having a family background which can contribute different views to the workplace – such as experiences of poverty or housing insecurity — are strongly encouraged to apply.
WSFSSH is an Equal Employment Opportunity Employer (EEO); employment is based upon employees’ qualifications without discrimination on the basis of race, creed, color, national origin, religion, sex, age, disability, marital status, sexual orientation, military status, citizenship status, genetic predisposition or carrier status, or any other protected characteristic as established by law.