Habilitation Coordinator

The Habilitation Coordinator duties are as follows:

The Habilitation Coordinator will serve as the PASRR evaluator when providing assessments for individuals being admitted into or diverted from admission into nursing facilities when there is reason to suspect the individual may have a mental illness or an intellectual developmental disability. The PASRR Evaluations (PE) must be completed with 72 hours of Bluebonnet Trails receiving the alert. The purpose of the assessment is to determine if the individual is eligible for PASRR specialized services related to their mental illness or intellectual developmental disability. The PASRR evaluator will present Community Living Options (CLO) and document findings on approved HHSC forms. Individuals who are eligible for PASRR Habilitative/Specialized Services require participation in the IDT meeting with the nursing facility staff to agree on specialized services for the individual and if the individual can be served in a less restrictive environment in the community.

The Habilitation Coordinator provides services to adults, residing in or being diverted from nursing facilities with intellectual developmental disabilities through assessment of needs, development of individual service plans, facilitating service linkages and monitoring for their effectiveness, provision of crisis intervention/prevention supports and the delivery of advocacy services. The ability to work with families and sensitivity to various agency and nursing facility personnel to accomplish objectives. The ability to work with families and sensitivity to various cultural differences is critical. The purpose for the position is to empower individuals served to achieve life goals and to live effectively while residing in a nursing facility and/or transitioning back into the community. The Habilitation Coordinator will participate in Service Planning Team (SPT) meetings, to monitor nursing facility continuing care plans and that services are delivered as per the plan on a monthly basis. The Habilitation Coordinator will assist in identifying any PASRR specialized services and present community living options to the individual and LAR on a regular basis.

The Habilitation Coordinator may serve in the role of a Service Coordinator when coordinating and monitoring transitions into the community when an individual identifies to the Habilitation Coordinator their desire to move. The Service Coordinator will convene and facilitate SPT meetings as necessary to conduct transition planning and to develop and implement the person’s transition plan. The Service Coordinator will conduct community tours with the designated resident to identify potential living situations as well as provide pre-move monitoring.

The Habilitation Coordinator may also serve in the role of Enhanced Community Coordinator when an individual transitions into the community. The Enhanced Community Coordinator monitors individuals for one-year post-transition. The Enhanced Community Coordinator will convene and facilitate quarterly SPT meetings as necessary to monitor the individual’s services and supports.

The Habilitation Coordinator is a special advocate for a vulnerable population of individuals residing in long-term care facilities. As a member of the Pre-Admission, Screening, Assessment and Resident Review (PASRR) Team, the Habilitation Coordinator coordinates services for adults with suspected mental illness or intellectual and developmental disabilities who are interested in living in the community with a variety of special supports instead of an institutional setting, or those who may need specialized behavioral health services as they reside in a nursing facility.

This position requires frequent use of initiative and independent judgment; assertive, professional intervention; frequent in person services, long-term contact with individuals, families and service providers; and the ability to work with minimal supervision. Job responsibilities require flexible hours and schedule to meet the needs of individuals. We encourage a flex schedule if a visit after hours or on a weekend is more appropriate to meet a family or individual’s needs.

Duties include providing habilitation coordination, intellectual and developmental disability (IDD) service coordination to a caseload of Nursing Facility residents to assure that appropriate services are delivered while they remain in the setting and assisting them to consider community living options if their needs can be met in a less restrictive setting. The ability to work collaboratively with others, including nursing facility personnel, Bluebonnet Trails Community Services provider staff, and families is necessary.

The person in this role will provide assessments for residents of nursing facilities and those requesting admission when there is reason to suspect the individual may have a mental illness or a developmental disability. The purpose of these assessments is to determine if specialized services related to their mental illness or developmental disability should be provided to the resident or if the individual requesting admission or newly admitted to a nursing facility could be served in a less restrictive setting in the community, diverting them from nursing facility admission. In the case of diversion, the Habilitation Coordinator provides referrals to needed supports in the community.

This position requires knowledge and skills in assessment, collaborative person-centered recovery, differential diagnosis as well as wellness and recovery-oriented systems of care.

The position will carry a small caseload of about 30 people and will make monthly face-to-face contacts with individuals on the caseload. All services are documented in an electronic health record and provided in collaboration with a multidisciplinary recovery team.

Location: Bastrop, TX

Hourly Salary Range: $21.46 – $28.71

Differential Detail:

• $0.75/hour Bilingual
• $1.00/hour Associate or Advanced licensure
• Up to $4.00/hour – Tenure with BTCS
• $0.50/hour – LCDC