General Description

Under supervision of the PASRR Supervisor and within federal, state and local guidelines, performs routine work meeting the needs of individuals with developmental disabilities. Work involves assessing and determining individual resident needs and developing appropriate programs.

The IDD Continuity of Care- PASRR position serves as the Enhanced Community Coordinator who works will all individuals diverting or transitioning from a Nursing Facility (NF) or State Supported Living Center (SSLC) as required in Attachment G of DADS Performance Contract. Responsibilities will be conducted in accordance with Attachment G of DADS Performance Contract, HCS Waiver principles, Medicaid requirements, ICF/IDD regulations, Center policies and procedures, TDMHMR contract, Permanency Planning and other state and federal laws as applicable. Works under moderate supervision, with limited latitude for the use of initiative and independent judgment.

Education, Training, and Experience

• Graduation from an accredited four-year college or university with major course work in human services or a related field to qualify as a Qualified Intellectual Disability Professional (QIDP), and one year human services experience.
• Experience as a member of an interdisciplinary treatment team and experience with the development and implementation of individualized program plans for both mental health, and intellectual and developmental disabilities preferred.
• Experience and education may be substituted for one another.

Registration, Certification, Licensure, and Other Qualifications

• Must have and maintain a background and criminal history free from any disqualifying offenses as outlined by the Texas Administrative Code (TAC) and the Health and Human Services Commission (HHSC).
• Must possess and maintain a valid driver's license and automobile insurance.
• Individuals with an out-of-state driver's license must be able to obtain a driver's license in the state of Texas within thirty (30) days.
• Successful completion of all position-specific training within thirty (30) days of employment is required.

Knowledge, Skills, and Abilities

• Knowledge of rehabilitation programs for individuals with developmental disabilities. Extensive experience in providing service coordination to individuals with IDD, including those who have complex medical needs.
• Skill in the operation of computers and in applicable computer software.
• Ability to collect and analyze data, to design therapeutic programs, to prepare and maintain records, and to communicate effectively.

• Ability to display regular and reliable (in-person, if required) attendance.
• Understanding and practice of Trauma Informed Care principles.

Essential Duties

The following list outlines key responsibilities for the position; however, it is not exhaustive and does not encompass all responsibilities. Additional duties may be assigned as needed.

• Ensure compliance with the rules governing service coordination for an individual with an intellectual disability (40 TAC, Chapter 2, Local Authority Responsibilities, Subchapter L, Service Coordination for Individuals with an Intellectual Disability)

• Provides intensive and flexible support to achieve success in a community setting, including arranging for support needed to prevent and manage a crisis, such as a Transition Support Team or crisis respite;
• Develops, and revises as necessary, using DADS Form 1050 (Diversion Plan) with an individual's service planning team (SPT)
• Using all available assessments, develops, and revises as necessary, with the individual's SPT an HCS Person-Directed Plan (PDP) Form 8665Person-Directed Plan), that identifies the individual's strengths and preferences, and medical, nursing, nutritional management, clinical, and support needs.
• Develops, implements, monitors, and revises as necessary, a client's Transition Plan to the Community, Phases II and III of the individual service plan, DADS Form 1041 (Individual Service Plan/Transition Plan - NF) with an individual's SPT.
• Provides increased coordination and interaction with an NF's care planning team and the assigned relocation specialist.
• Facilitates trial visits to providers in the community for the individual, including overnight visits where feasible, as requested by the individual.
• Researches alternate placements for individuals seeking residential services.
• Assists families and staff with state center applications and admission activities.
• Works as a team member by conducting and covering meetings when needed and by collaborating on placements for individuals in the community.
• Conduct service planning, ensures implementation of services, and monitors all services identified on the HCS PDP, including, reviewing the HCS program provider's implementation plans and provider records, as well as visiting service delivery sites, as needed to determine the individual's needs are being met.
• Ensures an individual receives timely assessments of behavioral, medical, nursing, specialized therapies and nutritional management needs, as necessary and as indicated on the HCS PDP.
• Inquires about any recent hospitalizations, emergency department contacts, increased physician visits, or other crises, including medical crises, and if the individual experiences such, convenes the SPT to identify all necessary revisions to the individual's HCS PDP to address additional need for services.
• Sends required quarterly reports to DADS for review.
• Monitors the individual face to face, on at least a monthly basis, for one year after transition or diversion.
• Provides pre- and post-transition services using DADS Form 1042 Pre-Move Site Review and DADS Form 1043 Post-Move Monitoring.
• Conducts service planning team meetings at least quarterly with the individual or LAR to review all waiver and non-waiver services in accordance with the HCS PDP.
• Documenting all communication in the individuals' charts.
• Maintains acceptable driving record as required for DCMHMR insurance.
• Assists individuals with enrolling into Waiver programs in a timely manner
• Perform additional duties as deemed necessary by department supervisor within designated timeframes.
• Works with minimal supervision.
• Successful completion of all staff development training as required for position.