1944.257—Service coordinator.
(a)
Each grantee must have at least one service coordinator who shall perform the responsibilities listed in section 802(d)(4).
(b)
The service coordinator shall comply with the qualifications and standards required by the Secretary concerned. The service coordinator shall be trained in the subject areas set forth in section 802(d)(4), and in any other areas required by the Secretary concerned.
(c)
The service coordinator may be employed directly by the grantee, or employed under a contract with a case management agency on a fee-for-service basis, and may serve less than full-time. The service coordinator or the case management agency providing service coordination shall not provide supportive services under a CHSP grant or have a financial interest in a service provider agency which intends to provide services to the grantee for CHSP.
(1)
Provide general case management and referral services to all potential participants in CHSP. This involves intake screening, upon referral from the grantee of potential program participants, and preliminary assessment of frailty or disability, using a commonly accepted assessment tool. The service coordinator then will refer to the professional assessment committee (PAC) those individuals who appear eligible for CHSP;
(2)
Establish professional relationships with all agencies and service providers in the community, and develop a directory of providers for use by program staff and program participants;
(5)
Complete, for the PAC, all paperwork necessary for the assessment, referral, case monitoring and reassessment processes;
(7)
Maintain necessary case files on each program participant, containing such information and kept in such form as HUD and RHS shall require;
(9)
Monitor the ongoing provision of services from community agencies and keep the PAC and the agency providing the supportive service informed of the progress of the participant;
(10)
Educate grant recipient's program participants on such issues as benefits application procedures (e.g. SSI, food stamps, Medicaid), service availability, and program participant options and responsibilities;
(12)
Assist the grant recipient in building informal support networks with neighbors, friends and family; and
(13)
Educate other project management staff on issues related to “aging-in-place” and services coordination, to help them to work with and assist other persons receiving housing assistance through the grantee.
(e)
The service coordinator shall tailor each participant's case plan to the individual's particular needs. The service coordinator shall work with community agencies, the grantee and third party service providers to ensure that the services are provided on a regular, ongoing, and satisfactory basis, in accordance with the case plan approved by the PAC and the participant.