Habilitation Coordinator

Bluebonnet Trails Community Services; Bastrop (TX); On-site; USD 30,000 - 40,000; Full time

Benefits offered by this job

Bilingual

Associate or Advanced licensure

Tenure with BTCS

LCDC

Job summary

Bluebonnet Trails Community Services is seeking a Habilitation Coordinator to assess residents of nursing facilities for PASRR eligibility and to coordinate community-based services. The role emphasizes collaboration with facility staff, families, and multidisciplinary teams to plan transitions and ensure appropriate supports are in place.

The position requires experience with IDD populations, a related bachelor’s degree, and the ability to work flexible hours to meet residents’ needs in

Qualifications

• At least one year experience working with individuals with Intellectual and Developmental disabilities.
• Bachelor's degree in psychology, social work, medicine, nursing, rehabilitation, counseling, sociology, human growth and development, physician assistant, gerontology, special education, educational psychology, or early childhood education/intervention.

Responsibilities

• Provide PASRR assessments for residents of nursing facilities or those seeking admission when there is reason to suspect mental illness or developmental disability.
• Develop individual service plans and monitor effectiveness; facilitate service linkages and crisis intervention as needed.
• Participate in Service Planning Team (SPT) meetings and monitor progress of nursing facility care plans; identify PASRR specialized services and present community living options.
• Assist in transition planning and community living options, including pre-move monitoring and coordination with families and facility staff.
• Serve as a special advocate for individuals and coordinate services to support community-based living when possible.

Skills

Bilingual

Clinical judgment

Case management

Education

Bachelor's degree

Job description

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 persons 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 individuals 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. J b 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 individuals needs.

Duties include providing habilitation coordination, intellectual and developmental disability (IDD) service coordination to a caseload of Nursing Facility residents to assure that appropriate services are delivered while they remain in the setting and assisting them to consider community living options if their needs can be met in a less restrictive setting. The ability to work collaboratively with others, including nursing facility personnel, Bluebonnet Trails Community Services provider staff, and families is necessary.

The person in this role will provide assessments for residents of nursing facilities and those requesting admission when there is reason to suspect the individual may have a mental illness or a developmental disability. The purpose of these assessments is to determine if specialized services related to their mental illness or developmental disability should be provided to the resident or if the individual requesting admission or newly admitted to a nursing facility could be served in a less restrictive setting in the community, diverting them from nursing facility admission. In the case of diversion, the Habilitation Coordinator provides referrals to needed supports in the community.

This position requires knowledge and skills in assessment, collaborative person-centered recovery, differential diagnosis as well as wellness and recovery-oriented systems of care.

The position will carry a small caseload of about 30 people and will make monthly face-to-face contacts with individuals on the caseload. All services are documented in an electronic health record and provided in collaboration with a multidisciplinary recovery team.

Location: Bastrop, TX

Hourly Salary Range: $21.46 - $28.71

Differential Detail

• $0.75/hour Bilingual
• $1.00/hour Associate or Advanced licensure
• Up to $4.00/hour - Tenure with BTCS
• $0.50/hour - LCDC

Join our dynamic and enthusiastic Team dedicated to continuously improving the health and independence of the persons we serve.

Minimum Qualifications

At least one year experience working with individuals with Intellectual and Developmental disabilities is required, this experience can be paid or unpaid.

A bachelors degree from an accredited college or university with a minimum number of hours that is equivalent to a major in psychology, social work, medicine, nursing, rehabilitation, counseling, sociology, human growth and development, physician assistant, gerontology, special education, educational psychology, or early childhood education/intervention.

• If degree is not in a human services field, a minimum of 24 college credits in a Human Services are required.

Meet Bluebonnet Trails Community Services driving requirements and maintain approved driving status throughout employment.

Preferred Qualifications

Previous experience completing assessments and providing case management/service coordination.

Bilingual in English/Spanish or ASL.

Experience and knowledge of Medicaid Waiver programs.

Demonstrated ability to use good clinical judgment, get along well with others and work effectively in a fast-paced setting.

Demonstrated computer and documentation skills.