Sault Tribe
  • - Government - Elder Care Services
  • Sault Ste Marie, MI, USA
  • 15.33
  • Hourly
  • Full Time
  • Yes


The Elder Outreach Worker, under the direction of the Elder Services Registered Nurse is responsible for establishing key relationships with Sault Tribe elders and families in the home, clinic, or community setting.  The Elder Outreach Worker assumes responsibility for coordinating programs and services to help tribal elders maintain a good quality of life and age in place. The primary scope is to travel to tribal elders' homes to assess and identify elders and family needs and finding resources to meet those needs. Areas of assistance may include physical, mental, psychological and/or social as it relates to aging.

ESSENTIAL FUNCTIONS (includes, but is not limited to, the following)

  • Responsible for networking with community organizations, and seeking affordable and new services to offer tribal elders.
  • Initiates and completes psychosocial assessments, interviewing patients, families and others in order to evaluate current condition and identify current or potential adjustments.
  • Provides general case management (and referral services) and maintains complete and updated files. Monitor and manage supportive services where necessary.
  • Complies with all Federal and State confidentiality regulations including but not limited to HIPAA.
  • Coordinates services for optimal living (i.e. aging in place and wellness philosophies).
  • Utilize appropriate documentation system to track all work done with tribal elders. Completes monitoring with tribal elders needing referrals and follows up on all services at and after implementation.
  • Provides Registered Nurse with regular status reports. 
  • Engage tribal elders to identify areas of need, and make necessary referrals. Organize and promote elder involvement in aging programs.
  • Assists in the coordination of home care services to enable independent living and aging in place. Including development of a Resource Directory that includes a list of service providers. Continually educates tribal elders (and staff) on a variety of matters including service availability, application procedures, patient rights, health/safety/fitness, issues relating to aging etc.  Assist with educational events related to health care, agency support, life skills and referral sources. Assists in the coordination of meals-on-wheels services, transportation, and any other service needs of tribal elders.
  • Coordinates counseling, occasional visits from a nurse, preventative health screening/wellness and legal advocacy.
  • Creates and maintains a positive atmosphere of customer service, including continuous quality improvement, teamwork, mutual respect and professionalism.
  • Attend and participate in all appropriate meetings and training opportunities in order to keep informed on current information and skill development.
  • All other duties as assigned


  • Provides assistance to Tribal members in completing applications for Tribal service programs. 
  • Promotes health program utilization.
  • Ensures clients safety and well-being.
  • Transports clients to and from visits and appointments.                                                 
  • Maintains documentation of client interaction.                                                                           
  • Establishes and maintains professional relationships with Sault Tribe Members, families and individuals in the home, clinic, school and community setting.
  • Reports any unusual findings to Elder Service Registered Nurse.
  • Maintains cleanliness of visit areas and vehicles.
  • Provides assistant to clients during visits.
  • Attends ongoing trainings.
  • All other job related duties as assigned.


Immediate peers, peers in other departments, immediate supervisor/manager, managers in other departments, customers and outside vendor/service providers.


Position medium with lifting of 50 pounds maximum and frequent lifting/carrying up to 25 pounds. Physical factors include constant use of hearing, smell, near/midrange/far vision, depth perception, color/field of vision; frequent standing walking, sitting, pushing/pulling, climbing, stooping, kneeling, reaching, manual handling, driving, typing, bending and assisting clients from sitting/lying position to standing position.  Working conditions include constant exposure to weather, extreme heat/cold, wet/humidity, and noise and air quality. Potential hazards include constant client contact, computer and equipment use; frequent infectious exposure and exposure to needles/syringes, and occasional exposure to electric shock and insecticides/pesticides.  Protective equipment/clothing needed to perform the job includes protective eye wear, masks, gloves and gowns.




Education: High School diploma or GED required.


Experience: One or more years of experience in a social service delivery with elderly and/or family population preferred. Demonstrated working knowledge of supportive services and other resources in the area served by the program. Demonstrated ability to advocate, organize, problem-solve, and provide results for the tribal elders served.


Certification/License: Must have a valid driver's license and be insurable by the Sault Tribe Insurance Department. Will be required to undergo and successfully pass a background check. Must maintain a good moral character standing. Must comply with annual driver's license review and insurability standards with the Sault Tribe Insurance Department. Will be required to complete and pass pre-employment drug testing.


Knowledge, Skills and Abilities: Knowledge of Tribal culture, practices, programs and community resources preferred. Knowledge of word processing and spreadsheet and data base software preferred. Knowledge of Electronic Health Record Charting preferred. Must be able to problem solve and handle situations appropriately. Must be able to work with minimal to no supervision. Knowledge of basic medical terminology required.  Knowledge of safety practices; Blood Borne Pathogens, and OSHA regulations as it pertains to Blood Borne Pathogens in the health care setting required. Must have organizational skills and be able to plan, prioritize and manage work load to meet goals in a timely manner. Basic knowledge of boundaries, delegation and scope of practice. Must be able to communicate effectively both orally and in writing. Must maintain confidentiality. Native American preferred.



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