Community Support Liaison

Job Description

Job Description

Job Title : Community Support Liaison

Supervisor: Center Manager 

FLSA Status : Exempt

Salary Range: See Salary Scale  

Job Summary: Serves as community liaison for Senior TLC. Responsibilities for this role include, but are not limited to, coordination of participants’ discharge from the hospital to a skilled nursing facility (SNF); coordination of transitioning participants to short-term rehab (STR)/respite to long-term care (LTC) when approved by the Interdisciplinary Team (IDT); and coordination of regulatory requirements/orientation for contract providers. This position’s primary focus will be to support the Transitional Care Program of Senior TLC as requested by the Center Managers, Medical Director, Executive Program Director, or as directed by the IDT team. This position reports directly to the Center Manager.

Education: High School Diploma or equivalent required. A graduate of an accredited school of nursing or relevant degree in Human Services preferred.

Experience : Minimum 1 year’s experience working with the elderly population.

Number and Type of Employees Supervised (optional) : None

Licensure, Registry or Certification : None 

Special Training: If licensed, must meet a standardized set of competencies for the specific position description established by Senior TLC and approved by CMS before working independently.

Immunizations: Be medically cleared for communicable diseases and have all immunizations up to date before engaging in direct participant contact

Ages of Patients Rendered Care: 

  Neonate/Infant Early Childhood Adolescent Adult Geriatric All Age Groups

Key Responsibilities : (*denotes an age-related skill or task)

• Coordinates all approved respite stays at contracted skilled nursing facilities (SNFs) and communicates details with Interdisciplinary Team (IDT) members, participants, caregivers, and SNF staff.
• Coordinates transitions of participants from short-term rehab (STR)/medical respite to long-term care (LTC) when approved by IDT as requested by the center manager and/or Medical Director.
• Serves as liaison to assist with coordination of discharge planning for STLC participants during hospital inpatient stays. Includes transitions to skilled nursing facilities and/or home.
• Provides frequent communication to caregivers and IDT members regarding discharge status, and admission status for STR/LTC.
• Coordinates and completes the orientation of new direct care contract providers [this would be Life Enrichment Center (LEC), Nursing Home (NH), or Home Care] 
• Provides oversight of direct participant care requirements for contracted providers. 
• Assists with Letter of Agreement and/or Contract with providers for Center Managers once approved by Executive Program Director & Medical Director.
• Serves as contact staff member for Senior TLC’s contract providers to reach out to if/when there are concerns. When contacted, communicate with the appropriate staff member within Senior TLC to address concerns.
• Enters appropriate outcomes/interventions in participants’ care plans as related to hospitalizations, hospital/SNF discharges, etc. 
• Updates EHR with admission/discharge dates for participants with inpatient stays as well as transitions from STR to LTC.
• Supports team members and functions as a team player while providing that support and adheres to the “do no harm” team contract statement. Accepts teammates’ differences in professional assessment findings, as they relate to participant care, and supports team decisions while promoting a united team for the participants’ continuity of care and for staff development.
• Supports his/her Interdisciplinary Team (IDT) and promotes unity among the team while interacting with the team, other co-workers, and/or participants. 
• Supports Senior TLC’s mission to encourage and support the quality of life of seniors wishing to continue living in the community; its vision to be the preferred provider of individualized care for seniors in the community; and its values of respect, integrity, accountability, compatible goals, and compassionate care. 
• Other duties as assigned.