Position Summary:

The primary function of the Support and Services at Home (SASH) Coordinator is to build trusting relationships with participants in SASH in order to develop a thorough knowledge of each SASH participant’s strengths and challenges as they pertain to remaining safely in his or her home.  The SASH Coordinator (SC) convenes the on-site SASH team on a regular basis to coordinate care and services to meet the needs of SASH participants.  The SC identifies and proactively responds to the underlying causes of any resident or community problems and/or issues and involves his/her Supervisor as needed. The SC organizes and facilitates resident meetings on a monthly basis and serves as key on-site contact for issues relating to housekeeping, noise, site disturbances, etc.  The SC issues lease violations and warning to residents and works with his/her supervisor on enforcement of the lease and resident handbook.

General SASH Coordinator Duties

  1. Prepares and disseminates SASH informational materials and assists in explaining the SASH model to residents and their family members/supports.
  2. Enrolls new SASH participants ensuring SASH enrollment documents are thoroughly explained and signed.
  3. Responsible for following all policies and protocols established for SASH as found in the SASH Operations Manual.
  4. Develops and maintains a regular calendar of activities and events for residents.
  5. Helps residents to build support networks with other residents, friends, and families.
  6. Adheres to confidentiality guidelines and appropriately documents information release.
  7. Recruits and trains volunteers in collaboration with the CSC Volunteer Coordinator and supervises resident volunteers in the provision of activities and programs in the CHLP.
  8. Escorts residents on field trips and outings as appropriate.
  9. 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 the Agency on Aging, UVMMC HHH, , local hospitals, nursing homes, senior centers, volunteer groups, etc.
  10. Participates in community outreach activities regarding SASH.
  11. Works independently and as part of the SASH team and CSC team to carry out job duties.
  12. Documentation and data entry in database systems – as required by SASH procedures, funding sources, grants, and other sources.
  13. Communicates in a positive and respectful manner with residents, community members, co-workers, visitors and family members.

Specific roles and responsibilities of the SASH Coordinator fall into three broad categories of interventions that the SASH model combines and provides for SASH participants in a holistic manner.  These three intervention categories are transitional care interventions, coordinated care interventions and self-management education interventions.


Principle Responsibilities by Intervention Category:

  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 SASH Admitting and Discharge Planning Protocols;
  • Follows all designated SASH Coordinator duties outlined in the Admitting and Discharge Planning Protocols including :
    • coordinates and communicates with Discharge staff at off-site facility,
    • communicates with family members/caregivers, make visits to participant in hospital or rehab facility as appropriate,
    • updates SASH team on participant’s transition status and confirm services to be available upon discharge,
    • makes in-person visit to participant within 24-48 hours of return home to identify needs and review discharge instructions,
    • coordinates and plans for any needed and unmet services with SASH team;
    • updates participant’s SASH health record and Healthy Aging Plan (HLP).
  1. Self-Management Education Interventions: The SASH Coordinator performs the following duties related to the self-education management interventions provided through the SASH system:
  • Develops the Community Healthy Living Plan (CHLP) in collaboration with SASH team and revises CHLP Action Plan every 6 months based on on-going assessment of the needs and opportunities of the housing community;
  • Identifies how best to offer the CHLP services/programs for SASH participants (bring existing community-based programs on-site, assist participants to participate in off-site programs, design new programs);
  • Provides 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, provide reminders and/or 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;
  • Coordinates and oversees volunteers (in collaboration with CSC Volunteer Coordinator) to support residents in meeting their HLP goals.
  1. 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;
  • Conducts person-centered interviews with all SASH participants to understand their interests, needs, ideas, concerns and opinions;
  • Coordinates the development of Individual Healthy Living Plans (HLPs)in collaboration with SASH team;
  • Meets with SASH Participants to discuss, gather input and finalize HLPs;
  • Coordinates and assists SASH participant with individual support needs and goals as identified in the HAP;
  • Acts as key contact person on site for information sharing regarding SASH participants among the SASH team, Wellness Nurse, 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 SASH team meetings- sets agenda, leads meetings and keeps summary notes;
  • Contributes information in the progress notes section of the SASH participant’s Health and Wellness Record;
  • 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, SASH team and SASH participant;
  • In communities where a Personal Care Attendant (PCA) is contracted for on-site services, the SASH Coordinator provides introductions to SASH participants and functional supervision to PCA in collaboration with Wellness Nurse and contracting agency.

 Performs other housing duties including:

  • Identifies and proactively responds to the underlying causes of any resident or community problems and/or issues and involves his/her Supervisor as needed.
  • Receives move-out notices from residents and forwards them to main office.
  • Follows up with residents regarding late-rent payments on a case-by-case basis.
  • Arranges and coordinates volunteers to conduct property tours
  • Conducts welcome interviews with new residents
  • Organizes and facilitates resident meetings on a monthly basis.
  • Coordinates family/resident meetings on an as-needed basis.
  • Develops a resident newsletter, involving as many residents as wish to participate in writing articles, layout, design, etc.
  • Promotes positive public relations whenever possible, for example: works closely with supervisor on the content of press releases regarding special events and generates sympathy, holiday, birthday and thank-you communications in coordination with CSC’s main office.
  • Serves as key on-site contact for issues relating to housekeeping, noise, site disturbances, etc.
  • Attends CSC staff meetings and external meetings as needed.
  • Contributes to regulatory or grant reports as needed.
  • Fills in for other SASH Coordinators during leaves or vacations.*
  • Fills in for other staff members as needed

 CSC Standards of Conduct:

  1. Demonstrates a commitment to the mission and values of CSC.
  2. Demonstrates respectful and effective communication with co-workers, residents, families and vendors.
  3. Protects the privacy and confidentiality of information related to residents, families, staff and general CSC operations.
  4. Communicates a positive image about CSC to the community.
  5. Conducts him/herself in a safe manner by adhering to all safety practices, rules and standards throughout the work day.
  6. Demonstrates a commitment to quality and proactively seeks to make improvements to systems and processes.
  7. Maintains a professional appearance that is appropriate for his/her position.
  8. Reports to work on time, provides advance notice for time off, completes timesheets accurately and appropriately manages CTO time.
  9. Demonstrates a commitment to integrity in work habits and use of CSC resources.
  10. CSC’s mission and operations require that an employee is prepared to perform duties as assigned that may be outside his/her principle responsibilities.

Minimum Qualifications:

Must possess a Bachelors Degree in Social Work or equivalent combination of background 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, and recreational activities is essential.  Demonstrated excellence in verbal and written communication is required. Must have knowledge of and an appreciation for the heritage, values, and wisdom of each resident 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 MSWord and Publisher is highly desirable.


Working Conditions and Physical Demands

  1. Must be able to lift/push up to 25 pounds.
  2. Exposure to body fluids, infection and odors and behavior of residents.
  3. Must be adaptable to working in a high stress work environment.
  4. Must be in good general health and demonstrate emotional stability in order to cope
  5. with the mental and emotional stress of the position.
  6. Must be able to lead resident field trips off site.

Note:  Non-Essential Duties are noted with an asterisk.