Community Transition Liaison

AgeSpan•Danvers, MA

2d•$27 - $29•Hybrid

About The Position

Since 1974 our agency has strived towards supporting an individual's desire to make their own decisions, secure their independence and remain living independently in the community. We are proud of our employees who make this possible every day. Our agency is a thought-leader, a nationally known generator of new ideas, because it welcomes creativity, your ideas. It is an outstanding place to work stimulating, friendly, collaborative. We offer competitive salaries, generous vacation time, and an excellent work/life balance. We value diversity and encourage career growth. If you have a passion for improving the lives of the elderly community and enjoy working in a diverse team driven by its mission, you've found the right place! At AgeSpan, you'll find a work environment that combines: A refreshing culture that is supportive, collaborative, and encouraging of diverse perspectives and backgrounds. A focus on innovation with a team recognized for developing and implementing innovative programs and novel solutions. Encouragement of your development through opportunities to get involved, use your voice, and gain new knowledge and skills. A satisfying balance between your work and personal life, including a flexible workplace, generous paid time off, and wellness programs. Depending on your role and your hours, we offer: Flexible schedule and hybrid work opportunities Competitive salaries Healthcare (medical, dental) 403b Retirement Plan with agency match 20 Vacation Days, 12 Sick Days, and 12 Paid Holidays Social Work Licensing Program License Renewal Paid by agency for RN's and Social Workers Mileage reimbursement Free parking Employee Referral Bonuses Employee Assistance Program Tuition Remission Program Commitment to promoting within Position Responsibilities: To function as a core member of the Community Transition Liaison Program Team (CTLP) with the focus being to assess the need and eligibility of residents who have been admitted to a care setting for discharge potential, assist with their transition back to the community when appropriate, and educate consumers about their long-term care options and appropriateness for community services. The Community Transition Liaison acts as the liaison between AgeSpan and our catchment area nursing facilities.

Requirements

BA/BS in social work, human services or related field required; case management and experience with the adult population preferred. Associate degree with significant relevant work experience can be substituted for portion of degree.
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.
Committed to ensuring the individual's voice, needs and preferences are supported to remain independent in the community. Promotes and values members dignity of risk and right to fail in a person-centered model of care.
Experience working with individuals with chronic health conditions and physical, developmental, and mental disabilities.
Reliable transportation and a valid driver's license required as field work is an essential component of the position.

Responsibilities

Acts as the onsite point of contact for residents, families, health care proxies (HCP)and Nursing Facility (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 to identify issues or problems that inhibit secure independent living at home to enable consumers to remain in the community.
Assesses a consumer's functional, health, and income status to determine eligibility and appropriateness for community long term care services or programs utilizing a standardized assessment tool.
Works with the consumers, formal and informal supports to develop a service plan which addresses the consumer's needs.
Ensures that consumers have access to public benefits and other community services.
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.
Coordinates with state programs and teams.
Completes required assessment tools, data entry and documentation in the A&D data system in accordance with the Executive Office of Aging & Independence standards. This can include case files and statistical records as required by the Agency and/or the Executive Office of Aging & Independence.
Provides consultation and education on services available.
Conducts post discharge visit to follow up on services and community supports and provide a warm handoff to ongoing case manager.
Maintains compliance with all mandated regulations of AgeSpan and the state and federal agencies.
Attends and participates in team, Home Care and general staff meetings as scheduled.
Participates in in-service training, educational offerings, and workshops to maintain professional expertise and develop additional skills.
Assists in the orientation and training of new staff members as needed.
Other duties as assigned.