Community Transition Liaison

Minuteman Senior Services•Burlington, MA

8d•$26•Remote

About The Position

Under the supervision and guidance of the Community Transitions Supervisor, the Per Diem Community Transition Liaison provides intermittent coverage, as needed, during a leave of absence and supports nursing facility residents (ages 22+) who want to consider transitioning to community setting. This service is inclusive of both short stay admissions and long-term tenure. The program involves assisting to meet the unique needs of sub-populations, including those with criminal justice system involvement, behavioral health needs, specific diagnoses and individuals experiencing housing insecurity, and/or those who may require specialized referrals to state programs and supports and to other agencies for transition needs which are best met through other agencies. ESSENTIAL FUNCTIONS: Under the direction of the Community Transition Liaison Program Supervisor: Community Transition Liaison supports nursing facility residents (ages 22+)

Requirements

Must be a self-starter and have the ability to work in a fast-paced environment with multiple interruptions.
Must possess excellent time management and problem-solving skills, along with the ability to establish and maintain professional boundaries and manage multiple priorities.
Must have accurate and fast data entry computer skills and experience using all Microsoft Suite programs.
Ability to work well with people of all backgrounds, incomes, ages, races, and disabilities (i.e., mental health, physical, cognitive, sensory).
Bachelor’s degree in social work, human services or related field preferred
Willingness and sensitivity for working with individual with complex health needs
Strong interviewing and assessment skills
Ability to listen and create person-centered plans
Strong written and oral communication skills
Ability to manage time in a fast-paced environment with many competing priorities
Strong computer skills include data entry, management of electronic health record, and Microsoft Suite
Familiarity with and/or willingness to learn about all relevant health and human service programs and agencies available
Must possess knowledge of long-term care, case management, discharge planning, community resources, programs and benefits to help an individual’s transition from an institution to a community setting
Must have reliable transportation and valid driver’s license in good standing

Responsibilities

Visit with residents to increase awareness of community supports and services and introduce transition as a potential option
Participate in resident and family conversations to inform options and transition plan
Conduct assessments to determine eligibility and help with planning transition to the community
Begin the process of gathering all necessary documentation and identification needed for application for housing and other public benefits
Complete referrals to other programs and follows-up on referrals to ensure timely transition
Identifies individuals appropriate for CTLP based on resident’s desire to transition to community living environment including use of PASRR portal to facilitate resident identification
Participates and facilitates in discharge planning meetings with the consumer, family, nursing facility staff and other agencies that will support the consumer in the community upon discharge
Liaison with nursing and other professionals at the SNF
Coordinate with state programs and teams
Complete Random Moment in Time Study (RMTS) as required by AGE.
Attend requirement meetings and complete required trainings
Other duties as assigned