Habilitation Coordinator

About the Role

The Habilitation Coordinator serves as the PASRR evaluator, providing assessments for individuals being admitted into or diverted from nursing facilities when there is reason to suspect the individual may have a mental illness or an intellectual developmental disability. PASRR Evaluations must be completed within 72 hours of receiving the alert. The purpose of the assessment is to determine eligibility for PASRR specialized services and present Community Living Options (CLO) while documenting findings on approved HHSC forms.

Individuals eligible for PASRR Habilitative/Specialized Services require participation in IDT meetings with nursing facility staff to agree on specialized services and determine if the individual can be served in a less restrictive community environment.

The Habilitation Coordinator provides services to adults in or being diverted from nursing facilities with intellectual developmental disabilities through needs assessment, development of individual service plans, facilitating service linkages, monitoring effectiveness, crisis intervention/prevention, and advocacy. The role empowers individuals to achieve life goals while residing in a nursing facility or transitioning back into the community.

The Habilitation Coordinator may also serve as a Service Coordinator when coordinating transitions into the community, convening and facilitating SPT meetings, conducting community tours, and providing pre-move monitoring. Additionally, the role may include serving as an Enhanced Community Coordinator, monitoring individuals for one year post-transition and facilitating quarterly SPT meetings.

This position requires frequent use of initiative and independent judgment, assertive professional intervention, long-term contact with individuals, families, and service providers, and the ability to work with minimal supervision. Flexible hours and schedule are required to meet the needs of individuals, including after-hours or weekend visits when necessary.

Responsibilities

• Complete PASRR evaluations within 72 hours of receiving an alert to determine eligibility for specialized services related to mental illness or intellectual developmental disability.
• Present Community Living Options (CLO) and document findings on approved HHSC forms.
• Participate in IDT meetings with nursing facility staff to agree on specialized services and assess if individuals can be served in a less restrictive environment.
• Provide habilitation coordination and IDD service coordination to a caseload of nursing facility residents to ensure appropriate service delivery.
• Assist individuals in considering community living options if their needs can be met in a less restrictive setting.
• Conduct assessments for nursing facility residents or those requesting admission when there is reason to suspect mental illness or developmental disability.
• Determine if specialized services are needed or if individuals can be diverted from nursing facility admission and served in the community.
• Provide referrals to community supports in cases of diversion.
• Participate in Service Planning Team (SPT) meetings to monitor nursing facility continuing care plans and ensure services are delivered as planned on a monthly basis.
• Assist in identifying PASRR specialized services and present community living options to individuals and their Legally Authorized Representatives (LAR) regularly.
• Serve as a Service Coordinator when coordinating transitions into the community, including convening SPT meetings, developing transition plans, conducting community tours, and providing pre-move monitoring.
• Serve as an Enhanced Community Coordinator for individuals transitioning into the community, monitoring them for one year post-transition and facilitating quarterly SPT meetings.
• Maintain a caseload of approximately 30 individuals, making monthly face-to-face contacts.
• Document all services in an electronic health record in collaboration with a multidisciplinary recovery team.
• Work collaboratively with nursing facility personnel, Bluebonnet Trails Community Services provider staff, families, and other stakeholders.
• Provide crisis intervention and prevention supports as needed.
• Advocate for individuals with intellectual developmental disabilities residing in long-term care facilities.

Requirements

• At least one year of experience working with individuals with intellectual and developmental disabilities (paid or unpaid).
• A bachelor's degree from an accredited college or university with a major or equivalent hours in psychology, social work, medicine, nursing, rehabilitation, counseling, sociology, human growth and development, physician assistant studies, gerontology, special education, educational psychology, or early childhood education/intervention.
• If the degree is not in a human services field, a minimum of 24 college credits in human services is required.
• Meet Bluebonnet Trails Community Services driving requirements and maintain approved driving status throughout employment.

Preferred Qualifications

• Previous experience completing assessments and providing case management/service coordination.
• Bilingual in English/Spanish or ASL.
• Experience and knowledge of Medicaid Waiver programs.
• Demonstrated ability to use good clinical judgment, work effectively with others, and thrive in a fast-paced setting.
• Strong computer and documentation skills.

Skills

• Knowledge and skills in assessment, collaborative person-centered recovery, and differential diagnosis.
• Understanding of wellness and recovery-oriented systems of care.
• Ability to work with families and sensitivity to cultural differences.
• Strong advocacy and crisis intervention/prevention skills.
• Ability to work independently with minimal supervision and use initiative and independent judgment.
• Flexibility in scheduling to meet the needs of individuals, including after-hours or weekend visits.
• Excellent collaboration and communication skills to work effectively with nursing facility personnel, provider staff, families, and multidisciplinary teams.

Pay

Hourly salary range: $21.46 - $28.71.

• $0.75/hour differential for bilingual skills.
• $1.00/hour differential for Associate or Advanced licensure.
• Up to $4.00/hour differential for tenure with Bluebonnet Trails Community Services.
• $0.50/hour differential for LCDC certification.

Location

Bastrop, TX.