Position Details

Transition Support Liaison

Transition Support Liaison

Job Code: TSL - 124
Revision Date: June 18, 2025

Starting Salary: $38.92 hourly; $80,944 annually

FLSA: 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

Emergence Health Network's (EHN) Transition Support Liaison (TSL) 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 liaison position must enhance coordination across local mental health serving systems, empowering individuals to successfully reside in their community of choice and to improve their quality of life and functioning.

The Transition Support Liaison identifies, provides, and coordinates support required by persons determined ready for discharge from a state hospital or a facility with a contracted psychiatric bed (CPB) authorized by Emergence Health Network. The Transition Support Liaison assists persons transitioning to community-based services by participating in joint discharge planning with the hospital. Additionally, the Transition Support Liaison conducts 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.

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.

  • The Transition Support Liaison shall complete training and participate in technical assistance activities required by HHSC.
  • The TSL must familiarize themselves with Title 26, Section 306 of Texas Administrative Code, and adhere to all standards as outlined in the code.
  • Perform at minimum monthly outreach to state hospitals or a facility with a CPB within EHN service area to establish a process for identifying persons for referral.
  • Focus on providing transition support services for individuals who meet the following criteria:
    • They have been admitted to and discharged from a state hospital facility three or more times during a 90-day period; or
  • They have resided in the facility for longer than 365 consecutive days.
  • The TSL shall design transition support services to complement joint discharge planning efforts with a state hospital or CPB, which must include:
    • Services and supports for persons to create viable discharge plans or outpatient management plans;
  • Coordinating and participating in initial service planning with the long-term outpatient treatment team, while ensuring that persons are discharged to the least restrictive environment.
  • The TSL shall design transition support services to complement joint discharge planning efforts with a state hospital or CPB, which must include:
    • Providing services and supports for persons to create viable discharge plans or outpatient management plans; and
  • Coordinating and participating in initial service planning with the long-term outpatient treatment team.
  • The TSL 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.
  • Conduct outreach and develop collaborative partnerships with other client-serving systems to coordinate resources and help facilitate access to appropriate community services by:
    • Participating in the development or enhancement of Memoranda of Understanding (MOU) with EHN leadership for client-serving agencies as they are identified;
  • Enhance referral procedures with EHN leadership for other client-serving agencies;
  • Update the local contact list of client-serving agencies and community resources that has been established to ensure accuracy of current local client-serving agencies.
  • Assist EHN Development Team on training and educating collaborative partners regarding support transition planning. Training should include but is not limited to information on EHN 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.
  • Assist EHN Development Team on training and educating the local community at a minimum biannually on EHN's role in providing behavioral health and transitional support services.
  • 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 supports.
  • Participate in other activities pre-approved by HHSC.
  • Assist with collection and submission of all applicable HHSC performance measure reporting items within the designated time frames allotted by HHSC.
  • Performs other duties as assigned.

Minimum Education and Experience Requirements

Requires a Master's Degree in Health or Human Services, Behavioral Health, Social Services or related field supplemented by four (4) years of progressive mental health or closely related field experience and two (2) years of supervisory experience; 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.

Required Knowledge and Abilities

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

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.
  • Other extreme hazards not listed above.
  • Works individuals who have been involved in the criminal justice system, probation and/or parole all hazards that may be associated with working in this environment, and with this population, will be applicable.

Special Certifications and Licenses

  • Requires Licensed Professional Counselor (LPC), Licensed Clinical Social Worker (LCSW), or Licensed Marriage and Family Therapist (LMFT).
  • 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.

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.

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.