Completes and ensures completion of documentation of clinical service, in participant’s medical records including initial assessments, re-assessments, change of status, temporary or permanent placements, hospital admissions and discharges, home and nursing home visits and other significant events according to Senior CommUnity Care documentation requirements. Provides ongoing support, counsel, and education to participants and family regarding a variety of issues, including but not limited to: the aging process, dementia, grief and loss, end of life, disease processes, difficult family dynamics and changing roles, PACE model and PACE health services.