Transition Coordinator

Position Overview:

Circle of Care St. Louis is seeking two dedicated and compassionate Transition Coordinators for a 6-month position, ending on June 30, 2024, with the possibility of extension. This role is essential to our mission of promoting the health, safety, and independence of our participants. Transition Coordinators will be responsible for comprehensive transition planning, coordination, and follow-up support to ensure successful community integration. They will collaborate directly with nursing facility residents, their families, physicians, service providers, and discharge nurses to develop care plans. The starting pay for this role is $19.50 to $20.00 per hour, with 40 hours per week. Reliable transportation is required.

Essential Duties and Responsibilities:

• Participant Engagement:
• Conduct face-to-face meetings with participants to develop personalized, person-centered transition plans.
• Work directly with nursing facility residents, their families, physicians, service providers, and discharge nurses to develop comprehensive care plans.
• Transition Coordination:
• Oversee all aspects of community transitions, including:
• Housing: Identify and secure appropriate housing solutions based on participant preferences and needs.
• Personal Care Support: Assess and arrange for necessary personal care services.
• Medical Needs: Coordinate medical and behavioral health services to ensure continuity of care.
• Community Integration: Facilitate connections to community resources and support networks.
• Transportation: Address and arrange transportation needs for participants.
• Assistive Technology: Identify and obtain necessary assistive devices and adaptive equipment.
• Employment/Day Activities: Support participants in finding suitable employment or engaging in meaningful day activities.
• Discharge Planning:
• Schedule and attend discharge meetings with nursing facility staff.
• Coordinate the date of discharge from the inpatient facility with various programs and services necessary for a safe and successful transition.
• Create linkages between inpatient facility residents, community agencies, housing programs, and other resources necessary for a safe and successful transition.
• Relationship Building:
• Establish and maintain working relationships with nursing facility and hospital staff, long-term care ombudsmen, social services staff, Medicaid eligibility staff, state and federal agency staff (e.g., Social Security Administration), In-Home Supportive Services (IHSS) staff, and others.
• Planning and Documentation:
• Develop thorough transition plans addressing all areas listed above.
• Maintain accurate and comprehensive documentation of all transition activities in required systems.
• Follow-Up Support:
• Maintain monthly contact with participants during the transition planning phase.
• Conduct bi-monthly community home visits for the first three months post-transition.
• Perform monthly follow-up visits for the remainder of the first year to ensure sustained community integration.
• Coordination with Service Providers:
• Collaborate with Home and Community-Based Services (HCBS) providers to arrange necessary services.
• Develop and maintain comprehensive 24-hour backup plans to address emergencies or unexpected needs.
• Monitoring and Reporting:
• Identify and report any concerns impacting participants' health, safety, or ability to remain in the community.
• Assist in locating participants for quality of life surveys to assess program effectiveness.
• Collaboration:
• Work in tandem with the Community Case Manager/Options Counselor to ensure cohesive and comprehensive support for participants.
• Compliance and Training:
• Ensure all required background checks and training are maintained.
• Stay updated on relevant laws, regulations, and best practices to ensure compliance and high-quality service delivery.

Education and Experience Considerations:

• Education:
• At least four years of college, vocational training, certification, or equivalent in a related field (health, nursing, or human services). Life and work experience with long-term care programs, home and community-based services, and programs serving seniors and/or persons with disabilities may be substituted.
• Bachelor’s degree in gerontology, social work, long-term care, health care management, or a related field is desired.
• Experience:
• Serving seniors with mental, physical, and/or functional impairments.
• Understanding of general Medicaid and/or Medicare benefits.
• Experience in long-term care services and care plan development.
• Experience in inpatient facility discharge planning.
• Proven experience working with the Social Security Administration.
• Familiarity with public housing processes and experience working with local Housing Authorities.
• Experience in obtaining Durable Medical Equipment (DME) for individuals.
• Background in coordinating Home and Community-Based Services (HCBS).
• Skills and Knowledge:
• Strong documentation and record-keeping abilities.
• Excellent interpersonal and communication skills, with the ability to build rapport with diverse populations.
• Ability to handle moderate to high levels of stress during times of consumer transitions and high call volumes.
• Flexibility to adjust communication and behavioral styles during transition periods and reporting deadlines.
• Understanding of Medicaid eligibility and nursing facility operations.
• Familiarity with discharge planning processes.

Physical and Emotional Demands:

• Physical:
• Ability to move and unload small to medium-sized items for home setup (e.g., microwave, chairs, end tables).
• Move small personal items into participants' new residences (e.g., pictures, clothes, personal items).
• Remain seated and operate computer/office equipment for extended periods.
• Operate office machinery, such as calculators, copy machines, fax machines, and printers.
• Emotional:
• Manage moderate to high stress during consumer transitions and high call volumes.
• Adapt communication and behavioral styles to meet diverse participant needs during transition periods and reporting deadlines.

Work Environment:

• Travel: Regular travel within the St. Louis metropolitan area to nursing facilities and discharge meetings.
• Setting: Combination of office-based and field-based work.
• Schedule: Standard business hours with some flexibility required to accommodate participant and facility schedules.
• Requirements: Must maintain appropriate licensure and background checks as per organizational and legal standards.

Salary : $20 - $20