The Community Transition Liaison (CTL) supports the dignity and independence of skilled nursing facility (SNF) residents (ages 22+) who wish to transition from an institutional to a community setting. As a member of the agency’s new Community Transitions Liaison Program (CTLP), the CTL serves as a key player in leading and facilitating successful transition planning by advocating, educating, and identifying options and resources to support resident goals and overcome barriers to discharge. The CTL will work directly with the CTLP Case Assistant, who will provide clerical and administrative support so that the CTL can work most efficiently. The CTL will serve as an onsite point of contact for SNF staff, residents, and their support system and will work closely with SNF and agency staff to identify residents who may benefit from working with the CTL. The CTL will strengthen and maintain strong working relationships with area SNFs and community service agencies to educate them on the role of the CTL. The CTL must be a creative problem-solver with strong assessment and person-centered planning skills.
Job Responsibilities and Performance Standards:
- Visits with SNF residents to increase awareness of community services and programs and introduces transition to the community as a potential option and alternative to institutionalization.
- Participates in resident and family conversations and in-person meetings to provide education and information on various community programs, options, and resources to aid in transition planning.
- Completes State Home Care Program intakes for SNF residents who wish to return to the community with State Home Care Program Services.
- Assesses residents’ situations, goals, and barriers to discharge through person-centered planning and needs assessments. Completes various screening tools to determine potential appropriateness for community-based programs and referrals to support residents’ transition to the community.
- Works closely with the CTLP Case Assistant to gather necessary documentation and identification needed for housing applications and other public benefits and community programs. Uses their knowledge of various community supports, systems, and services for older adults and persons with disabilities to recommend services and monitor the plan of care for quality and appropriateness.
- Works with the CTLP Case Assistant to arrange for, coordinates, and facilitates services and care linkages. Coordinates with state programs and internal and external stakeholders to ensure warm handoffs.
- Works closely and conducts outreach to SNF staff, residents, providers, and agency case management and nursing staff to identify individuals appropriate for CTLP and support discharge planning.
- Participates in and facilitates Interdisciplinary Discharge Planning (IDP) meetings and case conferences with residents, family, SNF staff, and others who will support the consumer in the community upon discharge.
- Maintains documentation, data entry, and records in an accurate, complete, confidential and timely manner according to state, federal, EOEA, and Agency regulations and guidelines.
- Conducts post discharge home visits and assessments as needed, to ensure SNF residents involved with the CTLP, are safe and stable in the community.
- Provide coverage for others as needed.
- Comply with HIPAA and other state and Agency confidentiality requirements.
- Perform other duties as assigned.
- If bilingual, provide interpretation and translation as needed.
Professional Standards and Conduct:
- Collaborative and Responsive: Regularly communicate, follow up, and use a team-driven approach. Respond thoughtfully and promptly to agency needs, requests, and inquiries; identify and build partnerships with key stakeholders. Demonstrates excellent organizational and time management skills to meet various deadlines, ensuring closed-loop communication. Ability to multi-task and maintain flexibility to adapt and adjust workload assignments based on various needs.
- Communication: Skilled in verbal and written communication, demonstrating the ability to communicate information in various ways to meet diverse styles and cultural backgrounds.
- Analytical: Critical thinking skills, using logic and reasoning to identify the strengths and opportunities of alternative solutions, conclusions, or approaches to problems.
- Attendance and Punctuality: Dependable, punctual, showing flexibility when needed. Attends meetings as needed and is fully present and participates during those meetings.
- Commitment: Embodies SCES’s core values and shows great integrity, accountability, and professionalism in all interactions. Aids in furthering SCES’s mission and commitment to an inclusive environment.
- Bachelor’s degree in social work, nursing, or a related field plus 1-2 years professional experience strongly preferred. LPN candidates with an accredited practical nursing certificate program and MA licensure may also apply.
- Must possess knowledge of long-term care, case management, discharge planning, community resources, programs, and/or benefits to help support an individual’s transition from an institutional to a community setting.
- Must be able to work independently and collaboratively with health professionals, community agencies, service providers, and agency staff.
- Must have strong written and verbal communication skills.
- Must be able to work with diverse populations.
- Exceptional time management and organizational proficiency.
- Must meet both CORI/SORI and public health screening requirements.
- Must be knowledgeable of and comfortable using Adobe and MS Word, Excel, SharePoint, and other
Microsoft 365 platforms. Experience with Wellsky and/or PASRR a plus.
- Must be able to travel to the office, clients’ homes, local community agencies, and area hospital and SNFs
via public transportation or by car. Hybrid office/work from home schedule opportunities available.
- Bilingual preferred.
- Physical surroundings are comfortable with minimal exposure to injury or hazards.
- Occasional stress due to periodic or cyclical workload pressures and deadlines. Some interruptions involved.
- Frequently sits, stands, walks, bends, reaches, and stoops throughout the day.
- Frequently lifts, pulls, pushes, and carries up to 20 lbs.
- Periodic eye strain and light ear strain.