State Hospital Continuity of Care Liaison

About the Role

The State Hospital Coordinator of Care ensures continuity of care for individuals transitioning in and out of the state hospital and moves BBT clients to the least restrictive environment. The role provides crisis intervention, assessment, and jail‑diversion services across eight counties, collaborates with a wide network of providers, and utilizes the BTCS electronic health record to monitor health indicators and coordinate care.

Responsibilities

• Maintain continuity of care services for individuals transitioning in and out of the state hospital.
• Facilitate placement of BBT clients in the least restrictive environment.
• Provide crisis intervention, crisis assessment, and jail‑diversion services within the eight‑county service area.
• Follow Article 16.22 of the Code of Criminal Procedures for jail diversion directives.
• Develop and sustain working relationships with jail personnel, County Courts, and County/District Attorneys.
• Identify individuals who may be candidates for BBT diversion programs or jail‑based treatment.
• Work to minimize incarceration length for individuals willing to follow outpatient protocols and court recommendations.
• Act as a bridge between discharging and receiving treatment teams, ensuring coordinated plan‑of‑care discussions.
• Facilitate warm‑hand‑off communications via email, telehealth case‑staffing meetings, or in‑person services to secure hospital or jail follow‑up within 7 days.
• Deliver culturally responsive, person‑centered, trauma‑informed services.
• Promote an integrated, holistic model of care at BTCS, a Certified Community Behavioral Health Clinic.
• Collaborate with mental‑health case managers, substance‑use providers, intellectual/developmental program coordinators, primary‑care physicians, and other internal/external service providers.
• Research and connect clients with local resources across the multi‑county region.
• Use the BTCS electronic health record to track referrals, missed appointments, crisis episodes, and other key health indicators.
• Complete Adult Needs and Strength Assessments (ANSAs), Child and Adolescent Needs and Strength Assessments (CANS), and Person‑Centered Recovery Plans (PCRPs).
• Facilitate recovery planning and support step‑down or graduation from services by linking clients to ongoing community support.
• Work on‑site; remote work requires approval from the Program Manager or designee.
• Report to the Program Manager for State Hospital Step‑Down Programs.

Requirements

Minimum Qualifications

• Bachelor’s degree in a social, behavioral, or human‑service field (e.g., psychology, social work, nursing, counseling, sociology, gerontology, criminal justice, etc.).
• At least 6 months of experience in case management, mental‑health crisis intervention, or service coordination.
• Willingness to work a flexible schedule to meet the needs of individuals and families.
• Proficiency with integrated computer database programs for accessing files, documenting treatment services, and organizing/prioritizing work assignments.
• Valid Texas driver’s license with maintained approved driving status.

Preferred Qualifications

• One year or more of case management/service coordination experience.
• Bilingual proficiency in Spanish or American Sign Language.
• Experience working in community mental health and/or a Local Mental Health Authority.
• Master’s degree in a human‑services field.

Pay

Hourly Salary Range: $21.46 – $28.71

• +$1.00 per hour for 2 years of previous experience.
• Up to +$4.00 per hour for BTCS tenure.
• +$0.75 per hour for bilingual proficiency.
• +$1.00 per hour for associate or advanced licensure.
• +$0.50 per hour for LCDC certification.

Benefits

Additional rewards and compensation, including an excellent benefits package and generous leave accruals, are detailed at https://bbtrails.org/work-with-us/.