Under direction of the Program Manager of MCOT On Call and within federal, state and local guidelines performs routine case management work. ?Work involves developing and maintaining long-term contact with clients, client families, and service providers for medical, social, educational, and related service needs. ?May train others.

The Continuity of Care Liaison acts as the liaison between Denton County MHMR Center and all of the state hospitals. The position is responsible for tracking consumers in the hospital and ensuring continuity of care by developing community support plans with the consumers and actively participates in discharge planning and coordination of outpatient services as needed. Works under moderate supervision, with limited latitude for the use of initiative and independent judgment while following the Center's Guiding Principles.

Education, Training and Experience (including licensure and certification)

Graduation form an accredited four-year college or university with a Bachelor's degree in a human services field as required to qualify as a Qualified Mental Health Professional (QMHP). One-year related experience working in mental health field required and experience working with individuals with intensive needs preferred. Prefer experience participating as a member of the interdisciplinary team in developing and implementing individualized program plans for mental health consumers.

REGISTRATION, CERTIFICATION, LICENSURE OR OTHER QUALIFICATIONS:

• Individual needs to meet the requirements to qualify as a Qualified Mental Health Professional (QMHP)
• This position requires you to maintain a valid Texas driver's license, auto liability insurance and a driving record acceptable to the Centers insurance requirements.
• This position requires adherence to all applicable laws, regulations, policies, procedures and/or guidelines of Health and Human Services Commission (HHSC) and Denton County MHMR. Other specific laws, regulations, policies, procedures and/or guidelines which must be followed include: Texas Administrative Code (TAC) and Case Management.

Knowledge, Skills and Abilities

• Knowledge of community resources, of case management delivery systems, and of program policies and procedures.
• Ability to assess individual's needs, to coordinate services, to communicate effectively, and to train others.
• Ability to maintain a calm and efficient demeanor during crisis situations.
• Ability to organize one's time and prioritize responsibilities which would enable one to complete all duties as assigned.
• Ability to work with individuals who may display symptoms of mental illness including; poor hygiene, difficulty controlling anger and low frustration tolerance, difficulty or inability to display appropriate social behavior, and who may present with symptoms of psychosis or may be suicidal or homicidal.
• Understanding and practice of Trauma Informed Care principles.

• Ability to make decisions based on education and or clinical experience, which reflect consistency with Center's Guiding Principles, Policies and Procedures, and Standards of Care.

Participates in the Center's Zero Suicide Initiative

• Assists individuals served during a crisis episode by ensuring they are linked to appropriate Center programs (MCOT, Psych Triage, CPT, etc.).
• Remains with individuals experiencing a crisis as needed.
• Completes CSSRS Since Last Visit at each contact with individuals served to determine risk level and ensure appropriate referrals.
  • Openly ask questions regarding Suicide to ensure accurate and thorough information is obtained.
• Provides additional support to individuals identified as at higher risk for suicide.
  • Educates individuals on the Suicide Care Pathway.
• Provides additional phone calls/support as required or requested.
• Seeks out to supervisor or other management to debrief on cases as needed.
• Assists with postvention efforts by completing aftercare appointments as identified below.

Essential Duties

1. Assists Denton County MHMR Center in the goal of reducing the rate of hospitalization in an effort to maintain consumers in the community.

• Complete stable discharge plan for individuals discharged from private and state hospitals.

1. Acts as liaison between Denton County MHMR Center and other agencies/ state hospitals through weekly travel to NTSH and frequent phone interactions with social workers and other treatment team members of other state hospitals and document interaction in consumer's chart.

• Assist with discharge planning and follow up on outpatient treatment services for individuals discharged from HHSC agencies/state hospital as needed.
• Completes 24 hour follow up calls to local psychiatric hospitals on individuals placed there for treatment and documents in consumers chart the same day.
• Actively collaborates with Social Workers and other treatment team members at local psychiatric hospitals on discharge planning for the consumer.

1. Ensures all consumers are met within 7 days of their discharge/furlough from a state hospital through coordination with the state hospitals.
• Communicates with management team regarding expected discharges through email, including all pertinent information needed to conduct an aftercare appointment.

• Communicates with social workers for discharge planning on individuals placed at state hospitals.
• Ensures all discharge documentation is received from referring state hospital.
• Assigns aftercare appointment on day of discharge through Xferall platform.
• Completes note for interaction and sends email to all necessary parties.
• Reviews 7 day follow up report weekly to ensure all items are completed and submitted.

1. Completes aftercare appointments on individuals released form the contract hospitals or state hospital the same business day and link those clients to appropriate center resources.

• Completes aftercares as assigned including all paperwork completed at time of aftercare.
• Assigns Case Manager and communicates via email new client along with any treatment recommendations. Copies new Case Managers supervisor on the email.
• Facilitates completion of Hospital Satisfaction Survey.
• Provides referrals as needed.

1. Monitors Client Assessment and Registration System (CARE) on a daily basis for admissions and discharges to the state hospital.

• Daily review of admission reports.
• Weekly review of 7 day follow up report.
• Discusses any discrepancies on the report with direct supervisor immediately.

1. Follows policies and procedures using company cars.
   • Signs company cars out prior to use and in after use.
2. Completes travel log in each car
3. Completes maintenance request upon identifying problems
4. Fills cars up with gas using center gas card when cars reach ¼ tank
5. Follows center policy regarding accidents in center vehicles or on center time.

1. Is familiar with all applicable TAC, fidelity tools, HHSC contract information, and Center policies and procedures.
   1. Documentation is completed within 2 business days and uploaded into Smart Care if applicable.
2. Complete all 24 hour follow up documentation the same business day.
3. Corrections completed within 2 business days.
4. Responds to emails within a timely manner.
5. Completes incident reports according to Center policy and procedures.

1. Completes tasks in a manner that fosters principle of creating a safe place for both staff and individuals.
   • Identify and report safety hazards to the appropriate manager.
2. Complete Incident Reports according to Denton County MHMR Policies and Procedures.

1. Attends all scheduled meetings.

• Meets with supervisor for monthly individual supervisions.
• Staff will attend all Crisis team meetings as scheduled and sign in for meetings to acknowledge their presence and understanding of the topics discussed.
• If a meeting is missed, staff will get with supervisor within one week to review the information.

1. Enters time worked and submits time sheets by center deadline.
• Submits all time off requests and punch requests in a timely manner and according to center policy.

1. Contacts supervisor or designated back-up for clarifications of procedures or clinical assistance as needed.

• Staff communicates urgent clinical and logistical needs with appropriate manager.
• Contacts Program Director for clarification of protocols or needed direction or assistance.

1. Provides emergency intervention when necessary according to HHSC and Center rules and procedures.
• Provides verbal and physical Prevention Management of Aggressive Behavior (PMAB) intervention correctly when necessary.
• Provides Cardiopulmonary Resuscitation (CPR) in an emergency until other medical aid arrives.
• Provides emergency and non-emergency first aid until professional medical aid arrives or as directed by licensed medical professional.
• Maintains all emergency intervention training according to Denton County MHMR Center policies and procedures.

1. Provides courteous, professional services at all times.
   • Maintains professional boundaries.
2. Interacts with center staff, clients, and community members in a professional manner.

1. Perform additional duties as deemed necessary by department supervisor within designated timeframes.

1. Interact with consumers, co-workers, and other community agency staff in a courteous and respectful manner.

1. Works in a team setting and provides support and assistance to other Crisis members as needed.

1. Has the ability to work independently and make decisions but seeks guidance when needed.