Community Transition Liaison

Old Colony Elder Services • Brockton, MA

1d

About The Position

OCES is growing and expanding to 11 more towns covering the south shore area, including Quincy, Braintree, Weymouth, etc. OCES supports older adults and individuals with disabilities by providing vital information and coordination of services. By promoting healthy, safe living for our consumers, we hope to allow them to stay active and engaged in their lives and in their own communities for as long as possible. Our mission: Through the talents of an experienced and diverse workforce, OCES supports the independence and dignity of older adults and individuals with disabilities by providing essential information and services that promote healthy, safe living which positively impacts our community. We are seeking a Community Transition Liaison to facilitate successful discharge activities and other support activities for assigned consumers focusing on the transition from nursing facilities (NF) to community. The Community Transition Liaison is responsible for facilitating successful discharge activities and other support activities for assigned consumers focusing on the transition from nursing facilities (NF) to community.

Requirements

• Bachelor's degree in nursing, social work, human services, or related field
• Current Social Work License preferred
• Must possess knowledge of long-term care, case management, discharge planning, community resources, programs, and benefits to help support an individual's transition from an institutional to a community setting
• Two years of experience in the social services field including a minimum of one year of experience with transition support activities
• Excellent verbal and written communication skills.
• Excellent interpersonal and conflict resolution skills.
• Excellent organizational skills and attention to detail.
• Strong analytical and problem-solving skills.
• Strong supervisory and leadership skills.
• Proficient with Microsoft Office Suite or related software

Responsibilities

• Acts as onsite point of contact for residents, families, health care proxy (HCP)and NF staff related to transitions from NF to community
• Visits with residents to increase awareness of service and introduce transition to the community as a potential option
• Participates in resident, family and/or HCP conversations to inform options and transition planning
• Completes the directional screening tool to determine potential appropriateness for referrals to HCBS Waivers and other programs to support the transition to the community and meet the consumer's needs once in the community setting
• Facilitates person-centered planning and needs assessment
• Begins the process of gathering necessary documentation and identification needed for housing applications and other public benefits
• Completes referrals to other programs and follows-up on referrals to ensure timely transition
• Participates in Interdisciplinary Discharge Planning (IDP) meetings and facilitates communication among the consumer, family members and community agencies.
• 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
• Coordinates with state programs and teams
• Maintaining case records in compliance with regulations, standards, and protocols
• Maintaining knowledge of current OCES policies and standards, and funding source regulations
• Other duties as assigned.

Benefits

• Ability to work with an enthusiastic team of like-minded individuals.
• Opportunity to develop professionally in your chosen career.
• Great work/life balance: 35-hour work week with some flexibility; no weekends
• Exceptional benefits: generous paid time off policies; company paid LTD and life insurances; 401K plan.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level