Competitive Compensation & Benefits Package! Position eligible for –
• Annual incentive bonus plan
• Medical, dental, and vision insurance with low deductible/low cost health plan
• Generous vacation and sick time accrual
• 12 paid holidays
• State Retirement (pension plan)
• 401(k) Plan with employer match
• Company paid life and disability insurance
• Wellness Programs
See attachment for additional details.
Office Location: Flexible for any of our office locations
Projected Hiring Range: Depending on Experience
Closing Date: Open Until Filled
Primary Purpose of Position:
The I/DD Transition Coordinator is responsible for coordinating and performing transition activities for members transitioning from state developmental centers or other institutional settings to the community. This position requires strong collaborative efforts with members and/or the member’s family members or guardian, facility providers and other relevant community service providers to make arrangement for individualized supports and services needed to be in place upon discharge. This employee must understand and embrace the use of multiple funding sources to support movement to less restrictive settings (e.g. Money Follows the Person, Long-Term Community Supports, community ICF-IID homes, etc.). This position requires strong collaboration with the Community Living Director, In-Reach Specialists, Transition Supervisor and Care Managers. Travel is an essential function of this position.
Role and Responsibilities:
The I/DD Transition Coordinator is responsible for (though not limited to) the following activities:
Transition Coordination
• Initiates and assumes primary responsibility for ongoing planning for effective and timely transition and continuity of care for
• Members residing in state developmental centers with a current Memorandum of Agreement (MOA)
• Members in a time-limited specialized program and have an identified discharge date within six months
• Members residing in state developmental centers or other applicable institutional settings for which Money Follows the Person applications have been requested and/or approved
• Members residing in state development centers or other applicable institutional settings referred by in-reach specialists
• Collaborates with the following individuals, specialists, and provider types as applicable depending on the member’s needs, participating in all transition meetings, either by phone or in person to ensure effective and timely discharge and transition to community:
• Member and/or the member’s family or guardian
• Facility providers
• Facility discharge planners
• Member’s care manager
• Member’s community-based primary care physician (PCP) once selected
• Peer support specialist or other individuals determined to have appropriate shared lived experience
• Educational specialists
• Other community providers and specialists as appropriate in the transition planning process, including physical health providers, behavioral health (BH) providers, and I/DD and/or traumatic brain injury (TBI) providers.
Pre-Transition Planning
• Participates in transition planning meetings on a quarterly basis, or more often if indicated, for those residing in state developmental centers who have expressed interest in exploring community options, have a current MOA, or are in a time-limited specialty program with an anticipated discharge date within six months
• Assists members and their families and facility staff in learning about funding options available to support transition
• Completes pre-transition support and risk mitigation to identify specific supports needed and plans for securing/developing needed supports:
• Current facility recommendations regarding the member’s staffing/support needs and preferences (ratios, training, adaptations, etc.)
• Specific supports needed and a plan for securing those supports including activities of daily living, budgeting, medical, medication and transportation.
• Member and LRP community-based interests, preferences and goals (e.g. county of residence, type of living arrangement, community involvement, etc.)
• Potential risks, risk mitigation and back-up supports including access to 24 hours resources as clinically indicated, housing support needs, medication assistance, medical support needs, adaptive equipment, mental health supports, money management, transportation, family dynamics, direct support staff training needs, preventing isolation (community involvement, school, volunteerism, employment, leisure, etc.), other risks unique to member.
• Benefit transfer needs
• Plan for securing/developing needed supports and identification of team member responsible for taking lead
• Transition timeline, inclusive of potential date for identifying residential/community provider
• Identifies and addresses other dynamics that impact the member’s ability to remain in his or her home or community: caregiver fatigue for members living with family or in an Alternative Family Living setting, effective household management (e.g., paying bills, household budgeting, lease compliance) and other dynamics as identified by transition coordinator or other care team members.
• Ensures participation of transition supervisor and designated member of clinical leadership in case discussions and transition planning for members with complex needs identified by facility clinical leadership (e.g., members with co-occurring disorders or a history of aggression and/or serious self-harm)
• Coordinates with the member, his/her family and natural supports and other members of the transition team to identify and secure the community resources necessary to transition. This includes but is not limited to:
• Residential setting and/or provider agency that exhibits the skills, abilities, and commitment to meet both the needs and preferences of the individual
• Medical care, including primary clinical specialists, and specialized therapies (inclusive of scheduling first appointments)
• Durable medical equipment needs and assistive technology needs
• Tailored Care Management
• Education and employment services
• Meaningful day services or supports
• Behavioral Health Services
• I/DD Services
• Behavioral challenges and resources to address the needs including development of behavior risk mitigation and crisis planning
• Needed social services and supports
• Transportation needs (nonemergency medical transport and community-based transportation options)
• Innovations or TBI Waiver Registry of Unmet Needs, as applicable
• Other community supports that are needed for community living, to meet the health and safety needs and address other dynamics that impact the member’s ability to remain in his or her home or community: caregiver fatigue for members living with family or in an Alternative Family Living setting, effective household management (e.g., paying bills, household budgeting, lease compliance) and other dynamics as identified by transition coordinator or other care team members
• Coordinating and conducting at least two face-to-face planning meetings with the member and transition planning team members.
Transition Planning (As Transition Approaches)
• Assesses the setting that the member is transitioning to for safety and appropriateness for the member using standardized checklist and notifies the transition planning team of any concerns or issues.
• Explores and secures appropriate and available funding options and work through any potential funding needs with community providers such as managing spend downs, if needed, prior to discharge.
• Conducts a Care Management Comprehensive Assessment to help inform both the 90 day post-discharge transition plan and the Individual Support Plan (ISP).
• Develops a 90 day post-discharge transition plan prior to discharge from the current setting, in consultation with the member, facility staff and the member’s care team, that outlines how the member will maintain or access needed services and supports, transition to the new care setting, and integrate into their community. The 90 day post-discharge transition plan shall be implemented upon discharge and be an amendment to the ISP/care plan.
• Ensures that the 90 day post-discharge transition plan incorporates any needs for training of parents and other caregivers to care for a member with complex medical needs post-discharge
• Provides a copy of the transition plan to all parties involved in the transition process
• Communicates with and provide education to the member and the member’s caregivers and providers to promote understanding of the ninety 90 day post-discharge transition plan
• Facilitates NC START’s participation in the final quarterly transition planning meeting, to the extent possible
• Works with NC START, facility staff and the community-based support staff to develop a residential staff training plan specific to the member that is inclusive of strategies for addressing the needs of the member in the context of a less structured community environment
• Engages NC START staff as participants in transition visits to the residential and other community settings to the extent possible and to accompany the member on the first day in the community, if determined to be needed during the transition planning process
• Ensures mitigation of risk of gaps in benefits, income and medication that may arise during the transition
• Coordinates Transition Year Stability Resources (TYSR) or Community Transition requests
• Facilitates a referral to Care Management (or to other entity providing care management after discharge – e.g. ICF-IID provider) 60 days prior to anticipated transition date, to support development of the member’s plan and a coordinated transition process.
• Ensures that the care manager is informed of status of transition planning, inclusive of any supports which have not yet been identified/secured
• Continues to take lead role in transition planning until the member’s transition, supporting the care manager in development of Individual Support Plan (ISP) and finalizing needed support planning
• Pays close attention to details at the time of transition, ensuring strong collaboration with identified Care Manager to promptly address any loose ends and unexpected issues
• Ensures that essential services are in place on the day of transition
• Assists member and legally responsible person in developing a contact list at time of discharge with names and contact information for all members of care team and others, as indicated
• Distributes contact list to member, legally responsible person and other members of care team
Discharge Day Support (on the day of discharge)
• Obtains a copy of the discharge plan and reviews the discharge plan with the member and/or the member’s family members or guardians and facility staff.
• Assists the member in obtaining needed medications and ensures an appropriate care team member or facility staff conducts medication reconciliation/management and supports medication adherence.
• Ensures effective and timely discharge and transition to appropriate community providers
Post-Discharge Follow-Up
• Ensures a warm handoff to the member’s care manager or other entity providing care management (e.g. ICF-IID provider) upon discharge.
• Continues to have active role on member’s care team following the warm hand-off until all emerging /identified issues are resolved or for 90 days post transition, whichever is longer
• Ensures timely, coordinated and sufficient follow-up to promptly identify and address emerging issues and track member’s post-transition experience
• For members moving to community living, facilitates post-discharge meetings with the institutional facility staff, care manager, residential or community service provider(s), LRP, and NC START team as appropriate. At a minimum, these post-discharge meetings must occur:
• Within 30 days.
• Three months post-discharge.
• Six months post-discharge.
• For members moving to community living, administers the Quality of Life Post-transition survey within 30 days prior to transition and again six months after transition and one year after transition.
• For members moving to a community ICF-IID facility, the ICF-IID Qualified Developmental Disability Professional (QDDP) will coordinate and facilitate post-discharge meetings with developmental center staff, provider agency, LRP, the NC START team (if appropriate), and LME/MCO as determined during the transition planning process and identified in the transition
Documentation and Reporting
• Documents all contacts with members or collaterals
• For members participating in the Money Follows the Person Program, completes required tracking and reporting
• For members residing in state developmental centers: Collaborate with the Community Living Director, if needed, to request an extension of Memorandum of Agreement in writing to the DSOHF Developmental Center Director prior to the discharge date outlining the reasons for the extension and anticipated length of extension needed.
Knowledge, Skills and Abilities:
• Demonstrated ability to effectively communicate and collaborate with individuals with I/DD and TBI
• Proven knowledge of state and federal policy, programs and laws impacting individuals with I/DD or TBI and their families
• Knowledge and ability to gather/analyze data for program evaluation and planning purposes
• Demonstrated ability to use good judgment and make data-based decisions
• Demonstrated ability to express directions, comments and opinions clearly and concisely in oral and/or written form
• Skill and ability to demonstrate diplomacy as well as the ability to handle stressful situations
• Demonstrated Ability to demonstrate initiative and effective, solution-focused, problem-solving skills
• Demonstrated ability to establish, maintain, coordinate and represent Partners efforts with diverse stakeholder groups, inclusive of self-advocates, families, and providers
• Proven knowledge of Medicaid policy and service delivery to people with I/DD, including the NC Innovations Waiver and other Long-Term Support Services
• Proven ability to build consensus among diverse stakeholders such as self-advocates, families, providers, advocacy groups, and providers
• A solutions-oriented mindset and orientation towards systems change and innovation
• Must be knowledgeable about resources, supports, services and opportunities required for safe community living for members with complex needs, including LTSS, BH, therapeutic, and physical health services
Education and Experience Required:
• Master’s degree in a human services field or licensure as a registered nurse (RN), plus one (1) year of relevant experience working directly with individuals with I/DD or TBI; or
• Bachelor’s degree in a human services field plus three (3) years of relevant experience working directly with individuals with I/DD or TBI.
AND
• Must reside in North Carolina
• Must have ability to travel regularly as needed to perform job duties
Education/Experience Preferred:
Experience working with individuals with co-occurring physical health and/or behavioral health needs preferred.
Minimum of two years of prior long-term support services and/or Home and Community Based Services coordination experience preferred.
Licensure/Certification Requirements:
If a Registered Nurse (RN), must be licensed in North Carolina.