Continuity of Care Liaison

Job Code: CWI - 111
Revision Date: November 14, 2024

Starting Salary: $18.59 hourly; $38,672.00 annually

FLSA: Non-Exempt

Overview

We are an agency committed to innovative behavioral health services in trauma-informed care that promote healing and recovery to instill a sense of empowerment and foster a lifelong sense of resilience.

General Description

The purpose of this job is to act as the primary Continuity of Care liaison for the agency and facilitate the smooth transition of clients from inpatient mental health care at a state mental health facility (SMHF) to community-based services. This position ensures that individuals discharged from the facility are connected to appropriate outpatient care, services, and resources, thereby supporting ongoing recovery and reducing the risk of readmission. Working closely with the state mental health facility and various community providers, the Liaison ensures continuity of care by developing and coordinating individualized discharge plans that address each client's unique needs, while adhering to all applicable sections of the Texas Administrative Code, specifically those related to mental health services, discharge planning, and continuity of care.

This class works under close to general supervision according to set procedures but determines how or when to complete tasks.

Duties and Responsibilities

The functions listed below are those that represent the majority of the time spent working in this position. Management may assign additional functions related to the type of work of the position as necessary.

• Collaborate with hospital staff (e.g., psychiatrists, social workers, case managers) to develop and implement discharge plans tailored to individual clients, in accordance with the Texas Administrative Code (TAC) guidelines for continuity of care.
• Work closely with outpatient mental health teams to ensure that clients have access to follow-up appointments and the necessary services.
• Administer and complete the Adult Strengths and Needs Assessment (ASNA) for all adult clients being discharged, and the Children and Adolescent Strengths and Needs Assessment (CANS) for minors, to ensure comprehensive evaluation of each individual's strengths, needs, and service requirements.
• Ensure that discharge plans are comprehensive, including follow-up appointments, medication management, therapy referrals, and community-based services.
• Assess the needs of clients, pre-discharge and ensure appropriate resources are in place to facilitate a smooth transition to outpatient care.
• Advocate for the needs and rights of clients, ensuring they receive appropriate treatment, services, and resources post-discharge.
• Maintain relationships with outpatient clinics to monitor client progress, identify any gaps in care, and ensure timely follow-up.
• Document all discharge-related activities, including care coordination, client communication, assessments, referrals, and follow-up care plans.
• Maintain accurate, up-to-date records of client interactions, treatment progress, and outcomes to ensure smooth handoffs between care teams and compliance with regulatory requirements.
• Generate reports as needed for local mental health authority stakeholders, ensuring data on discharge outcomes is captured.
• Stay updated on changes to TAC rules and implement them in daily practice to ensure full compliance with state requirements.
• Maintains compliance with all Joint Commission training requirements relevant to job duties, including but not limited to those dealing with the use of restraints and physical holding of individuals receiving services.
• Performs other duties as assigned.

Minimum Education and Experience Requirements

Requires a Bachelor's Degree in Psychology, Social Sciences or related behavioral field; or possession of any equivalent combination of education, training, and experience which provides the requisite knowledge, skills, and abilities.

Experience with trauma-informed services; cognitive behavioral therapies, including DBT; and motivational therapies including the use of incentives, preferred.

Minimum of two years of experience in mental health care, case management, or related fields, particularly in a clinical or hospital setting.

Experience with discharge planning, client advocacy, and working with diverse populations is strongly preferred.

Required Knowledge and Abilities

Knowledge of trauma-informed theories, principals, and practices (including multi-faceted understanding of concepts such as community trauma, intergenerational and historical trauma, parallel processes, and universal precautions), preferred.

Excellent communication and interpersonal skills to effectively collaborate with clients, families, healthcare professionals, and community service providers.

Strong organizational and documentation skills, with attention to detail and compliance with regulatory standards.

Ability to work independently and as part of a multidisciplinary team.

Physical Demands

Performs sedentary work that involves walking or standing some of the time and involves exerting up to 10 pounds of force on a regular and recurring basis or sustained keyboard operations.

Unavoidable Hazards (Work Environment)

• Involves routine and frequent exposure to:
• Bright/dim light; Dusts and pollen.
• Extreme heat and/or cold; Wet or humid conditions.
• Extreme noise levels, Animals/wildlife.
• Vibration; Fumes and/or noxious odors.
• Traffic; Moving machinery.
• Electrical shock; Heights.
• Radiation; Disease/pathogens.
• Toxic/caustic chemicals; Explosives; Violence.
• Other extreme hazards not listed above.

Special Certifications and Licenses

• Must possess or be able to obtain (upon hire) and maintain Qualified Mental Health Professional-Community Service (QMHP-CS) certification.
• Must possess and maintain a valid state Driver's License with an acceptable driving record.
• Must be able to pass a TB, criminal background and drug screen.

Americans with Disabilities Act Compliance (ADA)

Emergence Health Network is an Equal Opportunity Employer. ADA requires Emergence Health Network to provide reasonable accommodations to qualified persons with disabilities. Prospective and current employees are encouraged to discuss ADA accommodations with management.

Other Job Characteristics

• Staffing requirements, including criteria that staff have diverse disciplinary backgrounds, have necessary State required license and accreditation, and are culturally and linguistically trained to serve the needs of the clinic's patient population.
• Credentialed, certified, and licensed professionals with adequate training in person-centered, family centered, trauma informed, culturally-competent and recovery-oriented care.
• Responsible for adhering to the EHN common purpose and service framework to continuously provide exceptional care to all constituents.

Note: This Class Description does not constitute an employment agreement between the Emergence Health Network and an employee and is subject to change by the Emergence Health Network as its needs change.