SUMMARY:
Under the guidance of the Service Center Director and Associate Director, the Care Navigator plays an important role in the Meals on Wheels mission to provide “More Than a Meal.” The Care Navigator supports Service Center operations by providing needs assessments, advocacy, and resource coordination/referral to Meals on Wheels clients, helping them stay as healthy, safe and independent as possible. This role also assists in daily Service Center operations including ongoing client service, volunteer support, community outreach and senior networking.
DUTIES & RESPONSIBILITIES:
Client Management and Care Navigation:
- Communicate and coordinate with service center staff to review the status of clients who might benefit from extra support, intervention or community services.
- Manage and coordinate care plans for clients within assigned service areas, ensuring personalized and effective support.
- Engage with clients and their families to address concerns, provide guidance, and coordinate services that meet their evolving needs.
- Conduct field visits to assess client needs, ensure well-being, and update care plans as necessary.
- Monitor and follow up on Change of Condition Alerts related to client health or circumstances, ensuring timely intervention and support.
- Attend and actively participate in training to enhance knowledge of community resources and best practices for client support.
- Collaborate with fellow Care Navigators and the Associate Director of the More Than a Meal Program to balance caseloads effectively, engage in knowledge-sharing sessions, and contribute to special projects aimed at enhancing resources and support for clients.
Documentation and Reporting:
- Provide timely updates on client progress and report significant changes or concerns to the Service Center Directors, maintaining open communication for collaborative care.
- Record visit details, assessments, and care plan adjustments accurately, ensuring documentation is submitted promptly and reflects the client's current needs.
- Document all follow-up actions and outcomes related to Change of Condition Alerts in the client database, prioritizing reviews based on urgency.
- Maintain accurate, up-to-date client records while adhering to confidentiality standards.
Emergency Procedures:
- Respond promptly to client emergencies by contacting emergency services and notifying the Service Center leadership immediately, ensuring all incidents and follow-up actions are thoroughly documented.
- File Adult Protective Services (APS) reports and Wellness Checks as needed and follow up on filed reports within the assigned service area to ensure appropriate support and resolution.
- Adhere to Service Center emergency procedures for situations such as fires, natural disasters, or potential security risks, prioritizing client and staff safety.
Community Engagement:
- Participate in community outreach events and cultivate strong relationships with community organizations and senior service providers to promote Meals on Wheels and expand support networks for clients.
- Stay informed about senior services and resources offered by other organizations to better support client needs and make informed referrals.
- Collaborate with Service Center leadership, staff, and volunteers to effectively promote the Care Navigation Program and ensure seamless service delivery.
Service Center Operations:
- Process new client intakes, ensuring accurate documentation and clear communication of client service needs to Service Center representatives.
- Manage the client meal service database, overseeing meal scheduling and adjustments to ensure timely and accurate service.
- Assist with meal deliveries by covering routes as needed to support uninterrupted service.
- Update and maintain delivery route maps and reports to ensure accurate and efficient meal distribution.
- Perform other tasks and special projects assigned to support program operations and client care.
