Per Diem Community Transition Liaison

4 weeks ago

Burlington MA United States Minuteman Senior Services Full time
GENERAL SUMMARY:  
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:
  • 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; and
  • Coordinate with state programs and teams
  • Complete Random Moment in Time Study (RMTS) as required by EOEA.
  • Attend requirement meetings and complete required trainings
  • Other duties as assigned
COMPETENCIES NEEDED:
  • 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).
QUALIFIED APPLICANTS WILL HAVE:
  • Previous experience as an ASAP Care Manager or CTL.
  • Bachelor’s degree in social work, human services or related field required
  • 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

About Us

For almost 50 years Minuteman Senior Services has been helping older and disabled adults age with independence and dignity in the setting of their choice which is most often their own homes and communities. We have been supporting caregivers, local and long distance, who want to do the right thing for their loved ones and need help and advice as they balance the competing demands of family, work and self.

We offer over 20 programs and services and are continually improving and expanding. Our consumers give us very high marks as do our professional colleagues and that is very important to us. With over 140 employees, 900+ volunteers and over 70 subcontracted service providers that make up our vendor network we bring a lot of expertise, experience and resources.

Learn more by visiting our website:

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