Functions as a core member of the Community Transition Liaison Program (CTLP) to perform Case Management designed to assess the needs and eligibility of residents who have been admitted to a care setting for discharge potential, assist with their transition back to the community when appropriate, and educate consumers about their long-term care options and appropriateness for community services. The CTL acts as the liaison between ASNCM and our catchment area nursing facilities. 

• Acts as the onsite point of contact for residents, families, health care proxies (HCP)and Nursing Facility (NF) staff related to transitions from NF to community. 
• Visits with residents to increase awareness of services and introduces transition to the community as a potential option. 
• Participates in resident, family and/or HCP conversations to inform options and transition planning.
• Completes the directional screening tool to determine potential appropriateness for referrals to HCBS Waivers and other programs to support the transition to the community and meet the consumer’s needs once in the community setting.
• Facilitates person-centered planning and needs assessment to identify issues or problems that inhibit secure independent living to enable consumers to return to the community.
• Assesses a consumer’s functional, health, and income status to determine eligibility and appropriateness for community long term care services or programs, utilizing a standardized assessment tool.
• Works with the consumers, formal and informal supports to develop a service plan which addresses the consumer’s needs.
• Ensures that consumers have access to public benefits and other community services.
• Begins the process of gathering necessary documentation and identification needed for housing applications and other public benefits.
• Completes referrals to other programs and follows-up on referrals to ensure timely transition.
• Participates in Interdisciplinary Discharge Planning (IDP) meetings and facilitates communication among the consumer, family members and community agencies. 
• Coordinates with state programs and teams. 
• Completes required assessment tools timely and accurately, and enters data and documents in the A&D data system in accordance with EOEA standards. This can include case files and statistical records as required by the agency/EOEA. 
• Provides consultation and education on services available.
• Conducts post discharge visit to follow up on services and community supports and provide a warm handoff to ongoing case manager.
• Maintains compliance with all mandated regulations and the state and federal agencies.
• Other duties as assigned.
• Attends and participates in team, Community Resources, and general staff meetings as scheduled.
• Participates in in-service training, educational offerings, and workshops to maintain professional. 

Schedule: 35-hour workweek. Monday through Friday from 9 am to 5 pm.

QUALIFICATIONS AND EDUCATION REQUIREMENTS

• BA/BS in social work, human services, or related field required; case management and experience with the adult population preferred. An associate degree with significant relevant work experience can be substituted for portion of degree. 
• Must possess knowledge of long-term care, case management, discharge planning, community resources, programs and benefits to help support an individual’s transition from an institutional to a community setting.
• Committed to ensuring the individual’s voice, needs and preferences are supported to remain independent in the community. Promotes and values members dignity of risk and right to fail in a person-centered model of care. 
• Experience working with individuals with chronic health conditions and physical, developmental, and mental disabilities.
• Reliable transportation and a valid driver’s license are required, as fieldwork is essential to the position.

ESSENTIAL FUNCTIONS:

• Sufficient clarity of speech and hearing which permits communication with supervisor, co-workers, consumers, community professionals, and general public.
• Ability to talk on a phone, stand, walk, sit, and travel in the community.
• Ability to travel throughout the state of Massachusetts in a private vehicle under all weather conditions including snow.
• Ability to express ideas concisely and clearly, orally and in writing.
• Sufficient vision which permits production and review of a wide variety of materials, written correspondence, reports and related electronic and paper communication.
• Ability to lift and carry objects weighing 20 pounds.
• Ability to read and analyze data.
• Ability to exercise sound judgment in making decisions.

This is not an exhaustive list of responsibilities and requirements for the position. Other functions may be added at any time.