Transition Coordinator - LP; Buncombe​/McDowell​/Caldwell​/Burke

LOCATION

Remote - must live in or near Buncombe, McDowell, Caldwell, or Burke, North Carolina. This position will serve these counties. Incumbent must reside in North Carolina or within 40 miles of the NC border.

The Transition Coordinator LP (TC) is responsible for providing proactive intervention and coordination services to persons residing in or being diverted from institutionalized settings prior to their transition to home and community based services. These services prepare members/recipients for discharge and assist during adjustment period immediately following discharge from an institution. This is a mobile position with work done in a variety of locations.

The Transition Coordinator LP will work with members/recipients in their communities.

This position requires access to and use of confidential healthcare information or protected health information (PHI) as described in laws addressing patient confidentiality, including, but not limited to, the federal HIPAA law, the Confidentiality of Alcohol and Substance Abuse Patient Records law, 42 CFR Part 2, and various state laws. As such, the individual filling this position shall be required to be trained regarding such laws and shall be required to observe those laws in his/her capacity as an employee of Vaya Health.

The individual filling this position shall also sign a confidentiality statement as an employee of Vaya Health.

• Must be able to manage an active caseload of members/recipients in transition planning.
• Will work with manager to create a yearly target number of successful transitions based on state benchmark.
• Ensure that the Pre-Quality of Life survey is completed prior to lease signing date.
• Educate providers of tenancy support about their respective roles and responsibilities and of the TC's roles and restrictions.
• Adheres to boundaries within the In Reach, Transition, Diversion policy and does not provide services or supports outside of the scope of work.

• Ensure that monthly updates are received for transitioned members/recipients and submit auditing tool by deadline.
• Work alongside community providers (i.e., tenancy support, medical health, etc.) to ensure they are providing needed services
• Will be available for staffing and clinical consultation to other team members as needed

Leading the Transition Process:

The Transition Coordinator LP will work alongside the Transition Coordinator LP to ensure that any member/recipient who wishes to move to a more inclusive setting, from the adult care home or state psychiatric hospital, is provided with clinically indicated and appropriate behavioral health services and supports and In Reach staff, care management, and other Vaya departments necessary to ensure transition/discharge planning begins at admission to the facility.

The Transition Coordinator LP will assist in developing the transition team.

To facilitate a successful transition, the Transition Coordinator LP:

• Meet with the member/recipient, conduct clinical record review, and ensure completion of necessary assessments as needed. An assessment includes but is not limited to: diagnostic assessments, comprehensive clinical assessments, and psychological evaluations.
• Assists the member/recipient in developing an effective written plan which will include linkage to necessary treatment and crisis planning to enable the member/recipient to live independently in an integrated community setting.
• Networks with the member/recipient and the member/recipient's family and supports to develop a thoughtful, organized, holistic transition plan that addresses his/her community-based support needs.
• Ensures discharge/transition planning is developed and implemented through person-centered planning processes in which the member/recipient has a primary role and is based on the principle of self-determination while considering safety and well-being.
• Coordinate with the member/recipient, his/her family and supports to identify and secure the Community resources necessary to transition. Following basic hierarchical needs this includes but is not limited to: housing, behavioral health services, medical care, financial management, safety and security, and other community supports that are needed for community living.
• Develop diagnostic impression prior to linkage of services to ensure clinically appropriate services are in place during transition.
• Use motivational interviewing techniques to ensures a thorough North Carolina Person Centered Plan (NCPCP) is developed.
• Foster communication with institutions, provider agencies, and other community and natural supports that will be involved in the transition.

Transition Coordination function assumes responsibility for being responsive to the transition needs identified through the Department of Justice diversion process, ensuring a member/recipient requiring diversion from an Adult Care Home via the Referral Screening Verification…