Reports to: Program Supervisor

FLSA Status: Unpaid

Dedicate yourself to an Organization and Mission you can be proud of by joining the Western Reserve Area Agency on Aging!

Our Mission: We provide choices for people to live independently in the place they want to call home.

About Us:

Western Reserve Area Agency on Aging (WRAAA) is a private non-profit corporation, organized and designated by the State of Ohio to be the planning, coordinating and administrative agency for federal and state aging programs in Cuyahoga, Geauga, Lake, Lorain, and Medina Counties. It is one of twelve Area Agencies on Aging (AAAs) in the state organized with local service provider organizations and the Ohio Department of Aging (ODA) to form the state’s public aging services network. The network collaborates to create opportunities for older Ohioans to receive needed home and community services and support; and to age successfully in their own homes and communities.

Duration: This is an non-paid internship for the duration of the schools need.

Job Overview:

The Transitional Care Coach intern apart of the Business Development department will play a crucial role in assisting patients and families as they transition following hospital discharges, nursing home stays, ER visits, or observation periods. This role involves conducting comprehensive assessments focused on Social Determinants of Health and identifying potential caregiver burnout. The intern will be responsible for offering personalized support and linking individuals to community resources to ensure effective health management and continuity of care.

Key Responsibilities:

• Provide individualized coaching to patients and caregivers to enhance their understanding and management of health conditions post-discharge.
• Conduct in-depth assessments, addressing Social Determinants of Health to identify patients’ strengths and barriers to successful transition.
• Assess caregivers for burnout signs and offer necessary support and interventions.
• Collaborate with the multidisciplinary team to develop and monitor transitional care plans tailored to each patient’s unique needs.
• Educate patients and families about medical conditions, medication management, lifestyle changes, and the importance of attending follow-up appointments.
• Connect patients and caregivers with appropriate community resources, including food banks, housing assistance, caregiver support groups, and counseling services, addressing identified needs.
• Facilitate communication among patients, caregivers, and healthcare teams to ensure alignment in care plans.
• Coordinate with service providers for seamless delivery of services and referrals to support transitional needs, such as home health and social services.
• Monitor patients’ progress post-discharge, proactively addressing complications and providing timely interventions.
• Document and report patient and caregiver interactions, interventions, and outcomes in compliance with organizational and regulatory standards.
• Report any instances of abuse, neglect, or exploitation in accordance with Ohio regulations and program guidelines.
• Collaborate with healthcare providers to enhance practices and protocols related to transitional care.
• While most assessments are conducted over the phone, interns must have the ability and willingness to travel to all county service areas, including Cuyahoga, Lorain, Geauga, Lake, and Medina counties, to conduct in-person assessments as needed.

Qualifications:

• Enrollment in a Master of Social Work (MSW) program with completion of relevant coursework.
• Possession of a License Social Worker (LSW) in the state of Ohio.
• Excellent communication, motivational interviewing, and interpersonal skills.
• Ability to work both independently and collaboratively within a multidisciplinary team environment.

If you are interested in learning more about this opportunity, please click “Apply” and complete the application. We look forward to speaking with you.

The Agency is committed to providing equal employment and advancement opportunities to all. Employment decisions are made based on each person’s performance, qualifications, and abilities. The Agency does not discriminate in employment opportunities or practices on the basis of race, color, religion, gender, sex, national origin, age, disability status, health status, genetic information or ancestry, protected veteran status, sexual orientation, gender identity or expression, or any other protected characteristic.

Western Reserve Area Agency on Aging’s Equal Employment Opportunity policy covers all aspects of employment practices, including selection, job assignment, compensation, discipline, termination, and access to benefits and training.