General Description

The Community Hospital Liaison works under the leadership of the Program Manager of Liaison Services and oversees the continuity of care for individuals served in all local psychiatric hospitals. This position is responsible for maintaining a list of individuals in the local hospitals to ensure appropriate aftercare appointments are scheduled and completed. This position will work with individuals currently in local psychiatric hospitals to help develop treatment goals and provide appropriate resources and referrals. This position will actively participate in discharge planning, alongside the individual and hospital staff. This position will require in-person visits to local psychiatric hospitals.

This is a full-time position that works outside of the typical business hours. The schedule will be decided between the Community Hospital Liaison, Program Manager of Liaison Services, Director of Crisis Services, and the Chief Operations Officer. Hours will be determined based off the current needs of the program and individuals served. The ideal hours are posted in the above "schedule" section.

Education, Training, and Experience

• Bachelor's degree in a human services field (qualifying as a QMHP) required.
• Requires experience working with individuals diagnosed with a mental illness and experience with crisis intervention services.
• Preferred experience in a community mental health center and/or hospital setting.

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 local, state, and federal laws and regulations relevant to program areas.
• Knowledge and background in mental health services.
• Knowledge of serious and persistent mental disorders, personality disorders and substance use/dependence disorders encompassed in the DSM-5-TR.
• Moderate mathematics skills.
• Proficient reading, writing, interpersonal relations, and communicative skills; ability to read and comprehend simple instructions, short correspondence, and memos.
• Skills in using logic and reasoning to identify the strengths and weaknesses of alternative solutions, conclusions, or approaches to problems and in operating computers and applicable computer software.
• Ability to effectively present information in one-on-one and in group situations.
• Highly effective at working objectively with a diverse group of people and must demonstrate communication, organizational, administrative skills.
• Computer skills required for both clinical and clerical programs.
• Ability to make decisions based on education preparation and/or clinical experience, which reflect consistency with Agency philosophy, policies and procedures, and standards of care for both Denton County MHMR and local psychiatric hospitals in which the Center contracts with.
• 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.

1. Provide moderately complex case management/continuity of care services to individuals currently or recently discharged from psychiatric hospitals.
2. Acts as liaison between the Center and local psychiatric hospitals.
   • All interactions are documented in the individual's electronic health record.
3. Ensures all required discharge paperwork is obtained from the psychiatric hospitals.
   1. Discharge paperwork should be obtained through XFERALL for participating hospitals and via email for those that do not utilize XFERALL.
4. Maintains a list of individuals currently in each contract hospital to ensure follow-up and aftercare is provided.
5. Participates in discharge planning for all individuals in local psychiatric hospitals who have been assessed by the Center or entered the hospital on an emergency detention order, to ensure continuity of care.
   • Presents in person and/or virtually to local contract psychiatric hospitals as needed to meet with individuals served.
6. Obtain appropriate release of information documentation to share information with other community partners, as appropriate.
7. Completes aftercare appointments for individuals discharged from inpatient hospitalization within 7 days of discharge.
   • Aftercare appointments should be completed as soon as possible, post discharge.
8. At each aftercare appointment a C-SSRS Since Last Visit Form will be completed to assess for risk and potential need for a risk of harm assessment.
9. At each aftercare appointment the following should occur:
   1. All required paperwork will be completed.
10. Adults Needs and Strengths Assessment (ANSA) or Child and Adolescent Needs and Strength Assessment (CANS).
11. Person Centered Recovery Plan
12. Assigns case manager and attempts to introduce the individual to their case manager same day.
13. Communicates via email with case manager, appropriate managers, and appropriate staff.
14. Facilitate completion of Satisfaction Survey, regarding their stay at the hospital.
15. Provides referrals as needed.
16. Coordinate with clinic to schedule psychiatric evaluation for client continuing services with Denton Co. MHMR.
17. Assure appropriate hospital discharge information, including discharge medication, is communicated at the time of scheduling this appointment.
18. Uploading discharge clinicals to the electronic health record.
19. For individuals who decline services with the Center add them to the appropriate tracker and follow up within 1 week for continuity of care.
    1. Send caring contact (letter) to individuals after phone call.
20. Provide client crisis hotline and 988 number.
21. For individuals moving to out of Denton County location, provide 988 and LMHA (Local mental health authority) crisis hotline number.
    1. Add to the appropriate tracker and follow up within 1 week for continuity of care.
22. Completes 24-hour follow-up for individuals in local psychiatric hospitals via phone or face to face, as necessary.
23. All documentation should be entered into the electronic health record within 2 business days, in compliance with Center procedure.
24. Help coordinate client care while the individual is in the hospital. This may include but is not limited to helping coordinate connecting client to resources, paperwork needed to access resources, attending treatment team meetings with hospital staff, etc.
25. Review 7 day follow up report to ensure all individuals received appropriate follow-up post discharge.
    • Notifies supervisor immediately in the event there is no documented follow for an individual.
26. Complete all appropriate contact attempts (phone, home visit, letter) with individuals post discharge to make contact within 7 days of discharge.
    1. Document all contact attempts.
27. Coordinates with court liaisons regarding individuals who are in the hospital on an emergency detention order/involuntary recommendation.
    • Share information/communicate with Court Liaisons regarding treatment recommendations and risk reported.
28. Coordinate getting medication information for clients discharged from the court.
29. Coordinate with clinic to set up appropriate follow up appointment for clients discharged by the court.
30. Provide or facilitate transportation as deemed necessary.
31. Is familiar with Texas Administrative Code, HHSC guidelines, and Performance Contract information to ensure compliance.
32. Attends all scheduled meetings as assigned by supervisor.
33. Is familiar with all Center Policies and Procedures to ensure compliance.
    • Is responsible for reaching out to supervisor with questions.
34. Attends monthly supervisions.
35. All other duties as determined necessary by supervisory staff.
36. Participates in the Center's Zero Suicide Initiative.

o Supports individuals experiencing a crisis by promptly connecting them with appropriate Center programs, such as the Mobile Crisis Outreach Team (MCOT), Psychiatric Triage, Crisis Prevention services, and/or other applicable resources. Ensure seamless coordination to facilitate timely intervention.

o Remains with individuals, when deemed safe, to provide support and maintain a calm environment until specialized crisis staff or emergency personnel arrive to take over intervention efforts. Adheres to safety protocols to prevent escalation of the crisis situation.

o Participates in debriefing sessions with the immediate supervisor or designated staff following a crisis event. Collaborate with the team to review the incident, identify lessons learned, and ensure all HHSC guidelines and Center policies are followed.