Community Transition Liaison

The Community Transition Liaison (CTL) is a vital member of the Community Transition Liaison Program (CTLP), tasked with managing cases to assess needs and eligibility of residents in care settings for discharge back to the community. As a liaison between ASNCM and nursing facilities within the catchment area, the CTL educates consumers on long-term care options and facilitates transitions by developing personalized service plans and coordinating with various state programs and community services. This role is essential for ensuring a smooth transition from institutional to community living, supporting the consumer's independence and access to necessary services.

• Act as the point of contact for residents, families, and nursing facility staff, increasing awareness of community transition services.
• Complete screenings to determine eligibility for community services, facilitate person-centered planning, and assess consumer needs for a secure transition to the community.
• Develop service plans addressing consumer needs, coordinate documentation for housing and public benefits, and complete referrals to support community transition.
• Participate in discharge planning meetings, ensure timely and accurate data entry in accordance with EOEA standards, and maintain compliance with state and federal regulations.
• Conduct post-discharge visits, provide education on available services, and maintain professional development through in-service training and workshops.

• BA/BS in social work, human services, or a related field; significant relevant work experience can substitute for part of the degree requirement.
• Knowledge of long-term care, case management, discharge planning, and community resources to support transitions from institutional to community settings.
• Experience with individuals with chronic health conditions, and physical, developmental, and mental disabilities.
• Reliable transportation and a valid driver's license required for essential fieldwork across Massachusetts.
• Essential functions include clear communication, ability to travel in various weather conditions, lift objects weighing up to 20 pounds, and exercise sound judgment.