Hospital Liaison

Hospital Liaison

General Description

The Child and Adolescent (C&A) Community Hospital Liaison works under the leadership of the Program Manager of Liaison Services and oversees the continuity of care for children and adolescents served in all local psychiatric hospitals. This position is responsible for maintaining a list of individuals (C&A) in the local hospitals to ensure appropriate aftercare appointments are scheduled and completed. This position will work with individuals currently in local psychiatric hospitals to help develop recovery goals and provide appropriate resources and referrals. This position will actively participate in discharge planning, alongside the individual and psychiatric hospital staff. This position will require in-person visits to local psychiatric hospitals, residences of individuals served, and other community locations. This position will travel between Center locations as needed to meet the needs of individuals served.

This is a SMART Innovation grant funded position ending in August of 2027. Continued employment in this role is contingent upon the availability of additional funding. If further funding is not secured, the position will end on August 31, 2027.

Education, Training, and Experience
• Bachelor's degree in a human services field (qualifying as a Qualified Mental Health Professional (QMHP)) required.
• Requires experience working with individuals diagnosed with a mental illness and experience with crisis intervention services.
• Master's Degree in a human service-related field preferred.
• Preferred experience in a community mental health center and/or hospital setting.

Registration, Certification, Licensure, and Other Qualifications
• Must have and maintain a background and criminal history free from any disqualifying offenses as outlined by the Texas Administrative Code (TAC) and the Health and Human Services Commission (HHSC).
• Must possess and maintain a valid driver's license and automobile insurance.

o Individuals with an out-of-state driver's license must be able to obtain a driver's license in the state of Texas within thirty (30) days.
• Successful completion of all position-specific training within thirty (30) days of employment is required.

Knowledge, Skills, and Abilities
• Knowledge of local, state, and federal laws and regulations relevant to program areas.
• Knowledge and background in mental health services, experience working with C&A population preferred.
• Knowledge of serious and persistent mental disorders, personality disorders and substance use/dependence disorders encompassed in the DSM-5-TR.
• Proficient reading, writing, interpersonal relations, and communicative skills; ability to read and comprehend simple instructions, short correspondence, and memos.
• Proficient in the ability to demonstrate concurrent documentation while providing service delivery and maintaining accuracy and compliance standards.
• Skills in using logic and reasoning to identify the strengths and weaknesses of alternative solutions, conclusions, or approaches to problems and in operating computers and applicable computer software.
• Ability to effectively present information in one-on-one and in group situations.
• Highly effective at working objectively with a diverse group of people and must demonstrate communication, organizational, administrative skills.
• Ability to make decisions based on education preparation and/or clinical experience, which reflect consistency with Center philosophy, policies and procedures, and standards of care for both the Center and local psychiatric hospitals in which the Center contracts with.
• Ability to display regular and reliable (in-person, if required) attendance.
• Understanding and practice of Trauma Informed Care principles.

Essential Duties

The following list outlines key responsibilities for the position; however, it is not exhaustive and does not encompass all responsibilities. Additional duties may be assigned as needed.

1. Provide moderately complex case management/continuity of care services to individuals currently in or recently discharged from psychiatric hospitals.

o Accurately track and maintain a current list of child and adolescents served by the Center that are currently receiving inpatient care or have recently discharged from inpatient care.

o Collaborate with the individual's treatment team in the psychiatric hospital to develop a discharge plan, starting from date of admit to the hospital.

o Ensure all child and adolescents discharging from a local psychiatric hospital or contract hospital receive and complete an aftercare appointment day of discharge.

i. Appointments may be scheduled for the following business day or another day to meet the needs of the individual served and their families, not to exceed seven (7) days.

2. Acts as liaison between the Center and local psychiatric hospitals regarding all child and adolescent admissions and inquiries.

o Attends and actively participates in monthly meetings with the Center's contract hospitals.

o Responds to emails and phone calls from psychiatric hospital staff regarding discharges within 1 hour of receipt.

i. Reaches out to supervisor for assistance as needed.

o Attends treatment team meetings for individuals served as needed.

3. Assists with and leads community outreach efforts and trainings as needed.

o Will work with other liaison staff to provide community trainings aimed at increasing the community's knowledge of mental health services and resources.

4. Acts as co-chair for Denton County Community Resource Coordination Group.

5. Acts as backup to residential treatment center project coordinator.

6. Completes aftercare appointments for child and adolescents discharged from a local or contract psychiatric hospital.

o Aftercare appointments should be completed day of discharge, however, may be scheduled for the next business day at the request of the individual served or collateral.

i. The individual served must at minimum be spoken with on day of discharge, along with collateral to ensure no current risk is being reported and medication needs are met.

o At each aftercare appointment a Columbia Suicide Severity Rating Scale (C-SSRS) Since Last Visit Form will be completed to assess for risk and potential need for a risk of harm assessment.

o At each aftercare appointment the following should occur:

i. All required paperwork and tasks will be completed.

ii. Child and Adolescent Needs and Strength Assessment (CANS)

iii. Person Centered Recovery Plan

iv. Case manager assignment and attempt to introduce the individual to their case manager same day.

v. Communication via email with case manager, appropriate managers, and appropriate staff

vi. Facilitate completion of Satisfaction Survey, regarding their stay at the hospital

vii. Provide referrals as needed.

viii. Coordinate with clinic to schedule psychiatric evaluation for the individual served who will be continuing services with the Center.

ix. Assure appropriate hospital discharge information, including discharge medication, is communicated at the time of scheduling this appointment.

x. Upload discharge clinicals to the electronic health record.

o For individuals who decline services with the Center add them to the appropriate tracker and follow up within 1 week for continuity of care.

i. Call the individual/legally authorized representative to complete follow up.

ii. Send caring contact (letter) to individuals after the phone call.

iii. Provide client crisis hotline and 988 number.

o For individuals moving out of Denton County location, provide 988 and local mental health authority (LMHA) crisis hotline number.

i. Follow up via phone within one week to ensure continuity of care.

7. Completes 24-hour follow-up for child and adolescents currently in local psychiatric hospitals via phone or face to face, as necessary.

o Everyone who receives a risk of harm assessment by Center crisis staff must receive a follow up within 24 hours of the initial call.

8. All documentation should be entered into the electronic health record within two business days, in compliance with Center procedure.

o For documentation involving crisis situations documentation requirements may be less than 2 business days, as determined by crisis leadership staff.

9. Review 7 day follow up report to ensure all individuals received appropriate follow-up post discharge.

o Notifies supervisor immediately if no follow up has occurred for an individual served.

o Completes all appropriate contact attempts (phone, home visits, and/or letters) with individuals post discharge from a psychiatric hospital.

o All contact attempts must be documented in the Center's electronic health record (EHR).

10. Provide and facilitate transportation for individuals served, as needed.

11. Is familiar with Texas Administrative Code, HHSC guidelines, and performance contract information to ensure compliance.

12. Attends all scheduled meetings as assigned by supervisor.

13. Is familiar with all Center Policies and Procedures to ensure compliance.

o Reaches out to supervisor for clarification as needed.

14. All other duties as determined necessary by supervisory staff.

15. Participates in the Center's Zero Suicide Initiative.

o Supports individuals experiencing a crisis by promptly connecting them with appropriate Center programs, such as the Mobile Crisis Outreach Team (MCOT), Psychiatric Triage, Crisis Prevention services, and/or other applicable resources. Ensure seamless coordination to facilitate timely intervention.

o Remains with individuals, when deemed safe, to provide support and maintain a calm environment until specialized crisis staff or emergency personnel arrive to take over intervention efforts. Adheres to safety protocols to prevent escalation of the crisis situation.

o Participates in debriefing sessions with the immediate supervisor or designated staff following a crisis event. Collaborate with the team to review the incident, identify lessons learned, and ensure all HHSC guidelines and Center policies are followed.

General Description

The Community Hospital Liaison works under the direction of the Program Manager of Liaison Services and within federal, state, and local guidelines performs moderately complex case management, crisis, and outreach work.

The Community Hospital Liaison is responsible for developing relationships with all local psychiatric hospitals to ensure continuity of care for individuals served. This position is responsible for maintaining a list of individuals in the local hospitals to ensure appropriate aftercare appointments are scheduled and completed. This position will work with individuals currently in local psychiatric hospitals to help develop treatment goals and provide appropriate resources and referrals. This position will actively participate in discharge planning, alongside the individual and hospital staff. This position will require in-person visits to local psychiatric hospitals.

Education, Training, and Experience

• Bachelor's degree in a human services field (qualifying as a QMHP) required
• Requires experience working with individuals diagnosed with a mental illness and experience with crisis intervention services.
• Master's Degree in a human service-related field preferred.
• Experience in a community MHMR and/or hospital settings preferred.

Registration, Certification, Licensure, and Other Qualifications

• Active license through the state of Texas as a: Licensed Professional Counselor, Licensed Marriage and Family Therapist, or Licensed Clinical Social Worker is required.
• Possession of a valid driver's license and current automobile insurance.

o Individuals with an out of state driver's license must be able to obtain a driver's license in the state of Texas within thirty (30) days.

• Successful completion of all position-specific training within thirty (30) days of employment is required.

Knowledge, Skills, and Abilities

• Knowledge of local, state, and federal laws and regulations relevant to program areas.
• Knowledge and background in mental health services
• Knowledge of serious and persistent mental disorders, personality disorders and substance use/dependence disorders encompassed in the DSM-5-TR.
• Knowledge of common psychoactive medications used to treat neurobiological diseases of the brain.
• Proficient in moderate mathematics skills, reading, writing, interpersonal relations, and communicative skills; ability to read and comprehend simple instructions, short correspondence, and memos.
• Skills in using logic and reasoning to identify the strengths and weaknesses of alternative solutions, conclusions, or approaches to problems and in operating computers and applicable computer software.
• Ability to effectively present information in one-on-one and in group situations.
• Highly effective at working objectively with a diverse group of people and must demonstrate communication, organizational, administrative skills.
• Computer skills required for both clinical and clerical programs.
• Ability to make decisions based on education preparation and/or clinical experience, which reflect consistency with Agency philosophy, policies and procedures, and standards of care for both Denton County MHMR and local psychiatric hospitals in which the Center contracts with.
• Understanding and practice of Trauma Informed Care principles.

Essential Duties

The following list outlines key responsibilities for the position; however, it is not exhaustive and does not encompass all responsibilities. Additional duties may be assigned as needed.

Provide moderately complex case management/continuity of care services to individuals currently or recently discharged from psychiatric hospitals.

• Acts as liaison between the Center and local psychiatric hospitals.
• All interactions are documented in the individual's electronic health record.
• Ensures all required discharge paperwork is obtained from the psychiatric hospitals.

i. Discharge paperwork should be obtained through XFERALL for participating hospitals and via email for those that do not utilize XFERALL; requirements for each hospital are outlined in the respective contracts.

• Maintains a list of individuals currently in each contract hospital to ensure follow-up and aftercare is provided.
• Participates in discharge planning for all individuals in local psychiatric hospitals who have been assessed by the Center or entered the hospital on an emergency detention order, to ensure continuity of care.
• Presents in person and/or virtually to local contract psychiatric hospitals as needed to meet with individuals served.
• Obtain appropriate release of information documentation to share information with other community partners, as appropriate.
• Completes aftercare appointments for individuals discharged from inpatient hospitalization within 7 days of discharge.
• Aftercare appointments should be completed as soon as possible, post discharge (day of discharge is preferred).
• At each aftercare appointment a C-SSRS Since Last Visit Form will be completed to assess for risk and potential need for a risk of harm assessment.
• At each aftercare appointment the following should occur:

i. All required paperwork will be completed.

ii. Adults Needs and Strengths Assessment (ANSA) or Child and Adolescent Needs and Strength Assessment (CANS).

iii. Person Centered Recovery Plan

iv. Assigns case manager and attempts to introduce the individual to their case manager, same day.

v. Communicates via email with case manager, appropriate managers, and appropriate staff.

vi. Facilitate completion of Satisfaction Survey, regarding their stay at the hospital.

vii. Provides referrals as needed.

viii. Coordinate with clinic to schedule psychiatric evaluation for client continuing services with Denton Co. MHMR.

ix. Assure appropriate hospital discharge information, including discharge medication, is communicated at the time of scheduling this appointment.

x. Uploading discharge clinicals to the electronic health record.

• For individuals who decline services with the Center add them to the appropriate tracker and follow up within 1 week for continuity of care.

i. Send caring contact (letter) to individuals after phone call.

ii. Provide client with the crisis hotline and 988 number.

• For individuals moving to out of Denton County location, provide 988 and LMHA (Local mental health authority) crisis hotline number for that location.

i. Add to the appropriate tracker and follow up within 1 week for continuity of care.

• Completes 24-hour follow-up for individuals in local psychiatric hospitals via phone or face to face, as necessary.
• All documentation should be entered into the electronic health record within 2 business days, in compliance with Center procedure.
• Help coordinate client care while the individual is in the hospital. This may include but is not limited to helping coordinate resources, paperwork needed to access resources, attending treatment team meetings with hospital staff, etc.
• Review 7 day follow up report to ensure all individuals received appropriate follow-up post discharge.
• Notifies supervisor immediately in the event there is no documented follow for an individual.
• Complete all appropriate contact attempts (phone, home visit, letter) with individuals post discharge to make contact within 7 days of discharge.

i. Document all contact attempts.

• Coordinates with court liaisons regarding individuals who are in the hospital on an emergency detention order/involuntary recommendation.
• Share information/communicate with Court Liaisons regarding treatment recommendations and risk reported.
• Coordinate getting medication information for clients discharged from the court.
• Coordinate with clinic to set up appropriate follow up appointment for clients discharged by the court.
• Provide or facilitate transportation as deemed necessary.
• Is familiar with Texas Administrative Code, HHSC guidelines, and Performance Contract information to ensure compliance.
• Attends all scheduled meetings as assigned by supervisor.
• Is familiar with all Center Policies and Procedures to ensure compliance.
• Is responsible for reaching out to supervisor with questions.
• Attends monthly supervisions.
• All other duties as determined necessary by supervisory staff.

Zero Suicide Initiative

• Participates in the Center's Zero Suicide Initiative

o Assists individuals served during a crisis episode by ensuring they are linked to appropriate Center programs (MCOT, Psych Triage, CPT, etc.).

o Remains with individuals experiencing a crisis as needed.

o Completes CSSRS Since Last Visit at each contact with individuals served to determine risk level and ensure appropriate referrals.

• Openly ask questions regarding Suicide to ensure accurate and thorough information is obtained.

o Provides additional support to individuals identified as at higher risk for suicide.

• Educates individuals on the Suicide Care Pathway.
• Provides additional phone calls/support as required or requested.

o Debriefs with supervisor when there is a suicide death of an individual served or Center staff.