The Transition Support Liaison works under the leadership of the Program Manager of Liaison Services and provides intensive transition support and service coordination for children, adolescents, and adults with mental health needs, facilitating their transition from an inpatient to a community setting. The transition support liaison will enhance coordination across local mental health serving systems, empowering individuals to successfully reside in their community of choice in the least restrictive environment possible, and to improve their quality of life and functioning.
The transition support liaison will identify, provide, and coordinate support required by persons determined ready for discharge from a state hospital or a facility with a contracted psychiatric bed (CPB) authorized by the LMHA or LBHA. The transition support liaison will provide pre-transition support and resource coordination to persons admitted to a state-funded and private psychiatric hospital before discharge and short-term post-discharge follow-up.
For the purposes of Grant Agreement "continuity of care" refers to the process of:
1. Identifying the medical, psychiatric, or psychological care or treatment needs and educational or rehabilitative service needs of a person with medical or mental health conditions;
2. Developing a plan for meeting the treatment, care, and service needs of a person with medical or mental health conditions; and
3. Coordinating the provision of treatment, care, and services between the various agencies who provide treatment, care, or services such that they may continue to be provided to an individual at the time leading up to and after discharge from an inpatient setting.
Education, Training, and Experience
· Graduation from 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 the mental health field required and experience working with individuals with intensive needs preferred.
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.
o 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 community resources, case management delivery systems, and program policies and procedures.
· Ability to assess an individual's needs, coordinate services, and communicate effectively.
· Ability to maintain a calm and proactive demeanor during crisis situations.
· Skills 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, low frustration tolerance, difficulty or inability to display appropriate social behavior, symptoms of psychosis, suicidal ideations, or homicidal ideations.
· Skills 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.
· Ability to display regular and reliable in-person 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. The transition support liaison shall serve (or attempt to engage with) any person referred by a discharging state hospital or facility with a contracted psychiatric bed (CPB).
2. The transition support liaison shall complete training and participate in technical assistance activities required by HHSC. At a minimum, such activities will include evidence-based approaches to engage persons in their discharge plans.
3. The transition support liaison shall perform, at a minimum, monthly outreach to state hospitals or a facility with a CPB within the LMHA or LBHA service area to establish a process for identifying persons for referral.
4. The transition support liaison shall focus on providing transition support services for individuals who meet the following criteria:
o The individuals have been admitted to and discharged from a state hospital facility three or more times during a 90-day period; or
o The individuals have resided in the facility for longer than 365 consecutive days.
5. The transition support liaison shall design transition support services to complement joint discharge planning efforts with a state hospital or CPB, which must include:
o Providing services and supports for persons to create viable discharge plans or outpatient management plans; and
o Coordinating and participating in initial service planning with the long-term outpatient treatment team.
6. The transition support liaison shall participate in the development of a safety plan as identified by the person, legally authorized representative (LAR), if applicable, or others involved in the individualized treatment planning process.
7. The transition support liaison shall ensure that persons are discharged to the least restrictive environment with adequate support by collaborating with the LMHA or LBHA continuity of care team, hospital or facility, and other agencies to support service coordination and discharge planning.
8. The transition support liaison shall conduct post-discharge follow-up seven and thirty days after discharge to ensure seamless continuity of care and foster sustained engagement with long-term outpatient services.
9. The transition support liaison shall conduct outreach and develop collaborative partnerships with other client-serving systems to coordinate resources and help facilitate access to appropriate community services by:
o Participating in the development or enhancement of Memorandum of Understanding (MOU) with client-serving agencies;
o Developing or enhancing referral procedures with other client-serving agencies; and
o Developing or updating a local contact list of client-serving agencies and community resources.
10. The transition support liaison shall provide training and education to collaborative partners to support transition planning. Training should include but is not limited to information on LMHA or LBHA intake, assessment tools, client engagement, levels of care, system of care values, crisis services, mental health first aid, special programming, continuity of care, and transitional support services best practices.
11. The transition support liaison shall educate the local community at a minimum biannually on the LMHA or LBHA's role in providing behavioral health and transitional support services.
12. The transition support liaison shall develop or enhance referral procedures within the agency to ensure the connection of services between LMHA or LBHA programs.
13. The transition support liaison shall receive internal or external referrals to facilitate or participate in continuity of care case reviews for persons involved in multiple systems requiring transitional services and support.
14. The transition support liaison shall participate in other activities pre-approved by HHSC.
15. The transition support liaison shall not provide services unrelated to activities supporting transition services or maintaining successful community living.
16. The transition support liaison shall manage and submit monthly/annual reports to Denton County MHMR leadership and HHSC.
17. The transition support liaison shall manage and present, as needed, trackers indicating all individuals served within the program.
18. Attends all required meetings within The Center and with community partners.
19. All other tasks, as assigned by Program Manager of Liaison services, deemed appropriate by HHSC.
20. 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.
Full Time: Non-Exempt
Work Model: In-Person
Monday through Friday:10am-7pm
Pay Range: depends on qualifications
Full-time employees are eligible for full medical, dental and vision benefits. Part time employees are eligible for full medical and dental benefits. Incentives are available if employee chooses to participate in Center's Wellness Program.
Denton County MHMR Center is an approved NHSC (CMHC) and Pediatric Specialty with HRSA and Public Service Loan Forgiveness (PSLF) site.