(3035) State Hospital Continuity of Care Liaison

The State Hospital Coordinator of Care is responsible for continuity of care services for individuals transitioning in and out of the state hospital. This position is also responsible for moving BBT clients to the least restrictive environment. This position is responsible for providing crisis intervention, crisis assessment, and jail diversion services within the eight counties served by Bluebonnet Trails. Jail Diversion should be considered following the directives outlines in Article 16.22 of the Code of Criminal Procedures. This position requires a good working relationships with jail personnel and County of Courts including the County and District Attorneys. This positive will follow ongoing protocols for identification of individuals who may be good candidates for BBT diversion programs or at the very least for treatment within the jail system. This position will attempt to minimize the length for those incarcerated and willing to follow outpatient protocols and recommendations for the court systems. This clinician serves as a bridge between treatment providers, ensuring that the discharging treatment team and the receiving treatment team are connected and discussing the plan of care. This clinician may link providers through warm handoff email communication, facilitating telehealth case staffing meetings, or providing in person services as needed to ensure hospital or jail follow up occurs within 7 days.

The State Hospital Coordinator of Care provides culturally responsive, person-centered, and trauma-informed services. The position works within and promotes an integrated, holistic model for healthcare at BTCS, which is a Certified Community Behavioral Health Clinic.  The State Hospital Coordinator of Care collaborates with mental health case managers, substance use providers, intellectual and developmental program service coordinators, primary care physician offices, and other internal and external service providers to promote coordinated care for persons and families in need.  Services are provided to individuals across an eight-county region; therefore, this position requires an aptitude for researching and connecting with a variety of local resources across a multi-county area.

The State Hospital Coordinator of Care utilizes the Bluebonnet Trails Community Services (BTCS) electronic health record to monitor and address key health indicators and other dashboard information, such as referrals, missed appointments, crisis episodes, and more.  The Care Coordinator will also complete Adult Needs and Strength Assessments (ANSAs), Child and Adolescent Needs and Strength Assessments (CANS), and Person-Centered Recovery Plans (PCRPs) to address identified needs. Through surveys, assessments and monitoring care, this position will facilitate recovery planning and support step-down and graduation from services by linking to ongoing community support.

This position is based on site; remote work must be approved by the Program Manager or designee. This position reports to the Program Manager for State Hospital Step Down Programs.

Location: Williamson County

Hourly Salary Range: $21.46 – $28.71

Differential Detail:

• $1.00 per hour – 2 years previous experience
• Up to $4.00 per hour – BTCS Tenure
• $0.75 per hour – Bilingual
• $1.00 per hour – Associate Licensure or Advanced Licensure
• $0.50 per hour – LCDC

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

Click on https://bbtrails.org/work-with-us/ for additional details on other rewards and compensation, including our excellent benefits package and generous leave accruals!