Thank you for your interest in joining our team!

We are currently looking for a Lamoille County-based SASH Coordinator to join our team!

This position is based in a Morrisville office in Lamoille County. The Support And Services at Home (SASH) Coordinator works to build trusting relationships with SASH participants and potential participants in order to have a comprehensive understanding of each one of them—strengths, resources, needs and challenges. This is done in partnership with the SASH Wellness Nurse. The primary goal is to help them remain well in their home, through prevention measures, addressing needs and assisting during periods of crisis. So, the SASH Coordinator provides individualized support to participants in the many areas of health & well-being while also implementing the essential elements of the SASH program. An important element is connecting regularly with community partners including housers, food programs, agency on aging, senior centers, mental health agencies, medical offices and other community programs that support healthy aging.

General SASH Coordinator Duties

  • Participates in community outreach and marketing activities regarding SASH in order to maintain the minimum number of enrolled SASH participants for the size of the panel.

  • Organizes informational meetings and materials for promoting and explaining the SASH model to residents, community members and their family members/supports.

  • Enrolls new SASH participants ensuring SASH enrollment documents are thoroughly explained and signed. Re-enrolls participants on an annual basis.

  • Responsible for following all policies and protocols established for SASH as found in the SASH Operations Manual.

  • Develops and maintains a regular calendar of health & wellness activities and events for participants.

  • Helps participants build support networks with neighbors, other participants, friends, volunteers and family members. May also include seeking out informal community volunteers for particular needs or activities.

  • Adheres to confidentiality guidelines and appropriately documents information releases.

  • Establishes and maintains good working relationships, on-going liaison with, and an in depth knowledge of the services available from community organizations including but not limited to our partner agencies—Central Vermont Council on Aging, Central Vermont Home Health and Hospice, Washington County Mental Health Services, Community Health Team members in local PCP offices, Blue Print Healthy Living workshops, GMTA, local hospitals, nursing homes, senior centers, and other community organizations, etc.

  • Works independently and collaboratively as part of their specific SASH team, as an employee of Downstreet Housing and as part of the state-wide SASH program at Cathedral Square to effectively carry out job duties.

  • Completes essential trainings as determined by the SASH program and in collaboration with their Downstreet Housing manager.

  • Communicates in a positive and respectful manner with participants, community members, co-workers, partner agency staff, volunteers, visitors and family members.

 

Principal SASH Responsibilities by Intervention Category

Specific roles and responsibilities of the SASH Coordinator fall into three broad categories of SASH model interventions

  1. Transitional Care Interventions: The SASH Coordinator performs the following duties related to transitional care interventions through the SASH system:
    • Educates and informs SASH participants and family/support persons of the support provided for transitions in/out of the ER, hospital, same-day procedures or nursing facilities.

    • Follows all designated SASH Coordinator duties outlined in the Transitions Planning Protocols including:

      • Checks routinely for formal and informal notices of participants’ falls, ER visits, hospitalizations, same day medical procedures, and nursing facilities stay.

      • Communicates and coordinates as needed with social service staff at health facilities, participant and their support people.

      • Visits participant at home or in facility as appropriate, including attending any important team discharge planning meetings.

      • Updates SASH team members on participant’s transition status and confirm services scheduled upon discharge; plans with team for any other community services or other informal services needed.

      • Coordinates with wellness nurse to make in-person visit to participant within 24-48 hours of return home to identify needs and review discharge instructions and appointments.

      • Documents essential items into participant’s SASH health record and updates the Healthy Living Plan (HLP) as needed with any revised participant goals.

  2. Self-Management Education Interventions: The SASH Coordinator performs the following duties related to the health education & self-management interventions provided through the SASH system:
    • Explores ideas for the Community Healthy Living Plan (CHLP) in collaboration with the Wellness Nurse, SASH team and residents.

    • Identifies how best to offer CHLP services/programs for SASH participants (bring existing community-based programs on-site, assist participants to participate in off-site programs, design new health & wellness programs).

    • Writes up a formal CHLP Action Plan that can be shared as needed. Revises this CHLP Action Plan every 6 months based on on-going assessment of the needs and opportunities of the participant community.

    • Provides recommendations, referrals, encouragement and “coaching” to help participants be focused and motivated on proper self-management of their chronic conditions.

    • As requested or agreed to by participants, provides reminders and/or daily check ins to promote self-management skills.

    • Organizes and coordinates on-site educational presentations on health and well-being topics based on the collective needs of the SASH participant population as outlined in the CHLP.

    • Offers routine newsletter, social events and movement classes in hub sites.

  3. Coordinated Care Interventions: The SASH Coordinator performs the following duties related to the coordinated care interventions provided through the SASH system:
    • Arranges and schedules assessments of SASH participants to determine health and functional needs in collaboration with Wellness Nurse.

    • Meets or communicates weekly with Wellness Nurse to discuss individual participant issues and concerns, identifying priority participants for the nurse to visit.

    • Conducts person-centered interviews with all SASH participants to understand their values, interests, needs, concerns and perspective on their health & wellness.

    • After the SASH Wellness Nurse is completed, coordinates the development of their individual Healthy Living Plan (HLP) in collaboration with their desires and priorities, the SASH team offerings and recommendations, and information from their health providers.

    • Meets with SASH participants as appropriate to discuss the HLP, gather their input in order to initiate or update their HLP (The participant drives the ship).

    • Checks in and assists SASH participants around these goals identified in the HLP.

    • Acts as key contact person on site for information sharing regarding SASH participants among the SASH team, including Wellness Nurse, as well as discharge planning staff from hospitals and rehab facilities, family members and volunteers. This includes checking, documenting and communicating with team member for high risk participants in the CareNavigator system.

    • Convenes & facilitates monthly SASH team meetings- sets agenda, leads meetings and keeps (or delegates) summary notes following a structured team meeting format.

    • Documents relevant information in the health record regarding HLP, team meeting actions, group and individual health actions provided.

    • Communicates regularly and deliberately with SASH participants one on one and in groups to ensure consistent follow up and information sharing between SASH Coordinator, Wellness Nurse, other SASH team members and SASH participant.

Additional Responsibilities

  • Organize, establish and maintain essential office, home office or meeting spaces in hub sites in collaboration with manager.

  • Provide routine on-site presence at all hub sites with established in-person office hours.

  • Attend monthly Staff Meetings and other essential Downstreet Housing trainings/events.

  • Meet and communicate routinely with manager for essential planning, review and feedback.

  • Establish and maintain positive working relations with other Downstreet Housing staff.

  • Other duties as assigned in collaboration with your manager.

General Standards of Conduct

  • Care for yourself. Ask for help. Communicate openly with supervisor.

  • Team orientation: Demonstrate curiosity and respect for all the work teams at Downstreet and work to resolve challenges that might emerge.

  • Protect the privacy and confidentiality of information related to participants, residents, families, staff and general housing operations following HIPAA / housing requirements.

  • Adhere to all safety practices, rules and standards throughout the work day.

  • Demonstrate a commitment to quality and proactively seek to make improvements to systems and processes.

  • Maintain a professional appearance that is appropriate for the position.

  • Demonstrate a commitment to integrity in work habits and use of Downstreet resources.

Social Standards of Conduct

  • Positive interactions: whether in person, by phone/ text or email, communicate in a warm and respectful manner with residents, participants, co-workers, and community partners.

  • Establish and maintain good working relations with all Downstreet staff; work to build strong positive relationships that minimize personal issues with the SASH Team members. Seek solutions to issues that may come between you and someone else.

  • Demonstrate adaptability in order to working in a team environment with need for flexibility in priorities; and so be able to work through confusion from time to time.

  • Demonstrate appropriate emotional stability during times of stress & conflict with others.

  • Manage personal and work related stress without interfering with essential work duties.

  • Demonstrate respect, acceptance and a warm demeanor with all persons, especially with those marginalized in our society.

  • Demonstrate respect and a supportive attitude towards others even if their individual choices / beliefs differ from yours. Minimize those differences as much as possible in your work duties.

Physical Working Conditions

  • Work 37.5 hours per week doing traditional office tasks: using a laptop computer, filing, accessing copy / fax machine, meeting with participants in the building etc.

  • Able to lift/ push/ carry up to 25 pounds.

  • Driving a personal vehicle to access participant locations for programming tasks.

  • Able to perform all aspects of exercise and health programming tasks.

Minimum Qualifications

  • Must possess a Bachelors Degree in Social Work or equivalent social/ health/ community service field considered alongside a combination of background, training and experience.

  • Previous experience coordinating services specifically for the senior or adult with disability client population is preferred.

  • Knowledge of area resources and programs available to seniors and adults with disabilities, including transportation, health services, recreational and wellness activities is strongly preferred.

  • Demonstrated excellence in verbal and written communication is required.

  • Demonstrated ability to individually plan, organize and maintain complex tasks, files, email, calendar and program demands.

  • Must have knowledge of and an appreciation for the heritage, values, and wisdom of each participant and a commitment to the philosophy of a person’s choice to age at home.

  • Must possess a valid driver’s license.

  • A working knowledge of MS Word, Excel and Publisher is highly desirable as well as a proficiency in learning and using online databases relevant to SASH’s documentation system.

Employer Rights and Disclaimer

This job description is not a contract for employment. It is a list of activities, duties, responsibilities and expectations. However, it should not be considered a complete list of expected activities, duties, responsibilities or expectations. Duties, responsibilities and activities may change or new ones may be assigned at any time with or without notice.

This document does not extend an offer for permanent or continuous employment. Downstreet is an at-will employer. 

Downstreet is an equal opportunity employer and affords equal opportunity to all applicants for all positions without regard to race, color, religion, sex, national origin, disability status, protected veteran status, or any other characteristic protected by law.

Application Instructions

To apply online, please complete the form below. Please include a resume and a cover letter explaining why you would like to be a part of the Downstreet team. Applications submitted without a cover letter will be considered incomplete and will not be reviewed.

Downstreet is an equal opportunity employer, and all qualified applicants, including minorities, women, protected veterans, and individuals with disabilities are encouraged to apply.