1496) Habilitation Coordinator

The Habilitation Coordinator duties are as follows:

The Habilitation Coordinator will serve as the PASRR evaluator when providing assessments for individuals being admitted into or diverted from admission into nursing facilities when there is reason to suspect the individual may have a mental illness or an intellectual developmental disability. The PASRR Evaluations (PE) must be completed with 72 hours of Bluebonnet Trails receiving the alert. The purpose of the assessment is to determine if the individual is eligible for PASRR specialized services related to their mental illness or intellectual developmental disability.

The PASRR evaluator will present Community Living Options (CLO) and document findings on approved HHSC forms. Individuals who are eligible for PASRR Habilitative/Specialized Services require participation in the IDT meeting with the nursing facility staff to agree on specialized services for the individual and if the individual can be served in a less restrictive environment in the community.

The Habilitation Coordinator provides services to adults, residing in or being diverted from nursing facilities with intellectual developmental disabilities through assessment of needs, development of individual service plans, facilitating service linkages and monitoring for their effectiveness, provision of crisis intervention/prevention supports and the delivery of advocacy services. The ability to work with families and sensitivity to various agency and nursing facility personnel to accomplish objectives.

The ability to work with families and sensitivity to various cultural differences is critical. The purpose for the position is to empower individuals served to achieve life goals and to live effectively while residing in a nursing facility and/or transitioning back into the community. The Habilitation Coordinator will participate in Service Planning Team (SPT) meetings, to monitor nursing facility continuing care plans and that services are delivered as per the plan on a monthly basis.

The Habilitation Coordinator will assist in identifying any PASRR specialized services and present community living options to the individual and LAR on a regular basis.

The Habilitation Coordinator may serve in the role of a Service Coordinator when coordinating and monitoring transitions into the community when an individual identifies to the Habilitation Coordinator their desire to move. The Service Coordinator will convene and facilitate SPT meetings as necessary to conduct transition planning and to develop and implement the person’s transition plan. The Service Coordinator will conduct community tours with the designated resident to identify potential living situations as well as provide pre-move monitoring.

The Habilitation Coordinator may also serve in the role of Enhanced Community Coordinator when an individual transitions into the community. The Enhanced Community Coordinator monitors individuals for one-year post-transition. The Enhanced Community Coordinator will convene and facilitate quarterly SPT meetings as necessary to monitor the individual’s services and supports.

The Habilitation Coordinator is a special advocate for a vulnerable population of individuals residing in long-term care facilities. As a member of the Pre-Admission, Screening, Assessment and Resident Review (PASRR) Team, the Habilitation Coordinator coordinates services for adults with suspected mental illness or intellectual and developmental disabilities who are interested in living in the community with a variety of special supports instead of an institutional setting, or those who may need specialized behavioral health services as they reside in a nursing facility.

This position requires frequent use of initiative and independent judgment; assertive, professional intervention; frequent in person services, long-term contact with individuals, families and service providers; and the ability to work with minimal supervision. Job responsibilities require flexible hours and schedule to meet the needs of individuals. We encourage a flex schedule if a visit after hours or on a weekend is more appropriate to meet a family or…