Community Transition Liaison

JOB DESCRIPTION

Job Title: Community Transition Liaison (CTL)

Reports To: Senior Director of Nursing and Regulatory Affairs

Department: Home and Community Based Services, Care Transitions

FLSA Status: x Exempt or  Non Exempt

 Union or x Non-Union

Position Summary:

Driven by the mission of Somerville-Cambridge Elder Services (SCES) to support older adults and individuals with disabilities in maintaining dignity, independence, and choice in their communities, the Community Transition Liaison (CTL) leads person-centered transitions from skilled nursing facilities (SNFs) to community-based living. The CTL serves as a community transition specialist, engaging residents and families in informed decision-making while ensuring safe, sustainable discharge planning aligned with individual goals and preferences.

As a core member of the Community Transition Liaison Program (CTLP), the CTL conducts comprehensive functional and psychosocial assessments, applies strong critical thinking and case analysis, and develops individualized transition plans that address complex medical, behavioral, housing, psychosocial, and system-level barriers. The CTL balances compassionate advocacy with structured program accountability, ensuring adherence to program requirements and maintaining accurate, timely documentation that reflects comprehensive assessment, and individualized transition planning throughout the transition lifecycle, from enrollment through post-discharge stabilization and closure.

The CTL strengthens and maintains collaborative working relationships with area SNFs, community service agencies, housing providers, and internal teams to promote awareness of community-based alternatives to institutionalization. This role requires a highly organized, resourceful, and solution-oriented professional who can independently manage multiple complex cases while upholding SCES’s commitment to equity, integrity, and person-centered care.

Job Responsibilities and Performance Standards:

• Resident Engagement and Advocacy
• Conducts regular onsite engagement within SNFs to identify residents who may wish to transition to the community 
• Provide education to residents, families, and SNF staff regarding community-based services, programs and alternatives to institutionalization 
• Participates in resident and family care team meetings to support informed choice and person-centered decision making 
• Advocates for resident dignity, independence and self-determination throughout the transition process 
• Visit SNF residents to increase awareness of community services and programs and introduces transition to the community as a potential option and alternative to institutionalization

• Assessment and Transition Planning
• Conducts comprehensives transitional assessments to evaluate readiness or needs for community discharge 
• Identifies barriers to discharge, including housing, medical, behavioral, financial and system-level challenges
• Completes required screening tools, intakes, and assessments to determine appropriateness for community-based programs and referrals
• Develops individualized transition plans that reflect resident goals and assessed needs 
• Participates in and facilitates Interdisciplinary Discharge Planning (IDP) meetings and case conferences with residents, family, SNF staff, and others who will support the consumer in the community upon discharge.

• Transition Coordination and System Navigation
• Works closely with the CTLP Case Assistant to gather required documentation and support benefit and housing-related applications and other public benefits and community programs
• Uses their knowledge of various community supports, systems, and services for older adults and persons with disabilities to recommend services and monitor the plan of care for quality and appropriateness.
• Works with the CTLP Case Assistant to arrange for, coordinates, and facilitates services and care linkages. Coordinates with state programs and internal and external stakeholders to ensure warm handoffs.
• Works closely and conducts outreach to SNF staff, residents, providers, and agency case management and nursing staff to identify individuals appropriate for CTLP and support discharge planning
• Coordinates with state-funded transition supports and public programs to facilitate safe and timely community discharge

• Documentation and Program Requirements
• Completes documentation in a timely and accurate manner in accordance with state, federal, AGE, and agency regulations and guidelines 
• Maintains organized, thorough records that reflect assessment findings, transition planning and case progression 
• In collaboration with the Case Assistant, ensures enrollment, transition and termination activities are documented appropriately and timely 
• Supports data accuracy and timely case updates to promote program integrity 
• Maintains documentation, data entry, and records in an accurate, complete, confidential and timely manner according to state, federal, EOEA, and Agency regulations and guidelines
• Conducts post discharge home visits and assessments as needed, to ensure SNF residents involved with the CTLP, are safe and stable in the community

• Collaboration and Community Partnership
• Strengthens and maintains collaborative relationships with area SNFs, community agencies, housing providers, and other stakeholders
• Educates partners on the role of the CTLP and promotes community-based options
• Communicates professionally and responsively with residents, families, facility staff, and internal teams
• Provides coverage and cross-team support as needed
• Complies with HIPAA and all agency confidentiality requirements
• If bilingual, provide interpretation and translation as needed.

Professional Standards and Conduct:

• Collaborative and Responsive: Regularly communicates, follows up, and uses a team-driven approach in supporting resident transitions. Responds thoughtfully and promptly to agency needs, requests, and inquiries while building strong working relationships with SNF staff, community partners, and internal teams. Demonstrates solution-oriented thinking and persistence when navigating systemic or housing barriers and exercises sound judgment in complex transition situations
• Communication: Skilled in verbal and written communication, with the ability to adapt communication style to meet diverse cultural backgrounds and learning styles. Ensures documentation clearly reflects assessment findings, critical thinking, and individualized transition planning. Maintains professionalism and composure in high-stress or sensitive situations.
• Analytical and Organizational: Applies strong assessment skills and critical thinking to evaluate resident needs, identify barriers to discharge, and develop thoughtful transition strategies. Demonstrates excellent organizational and time management skills to manage multiple concurrent transitions while meeting program expectations.
• Attendance and Punctuality: Dependable, punctual, showing flexibility when needed. Attends meetings as needed and is fully present and participates during those meetings. 
• Commitment and Professionalism: Embodies SCES’s core values of dignity, integrity, and accountability. Maintains appropriate professional boundaries, ethical standards, and confidentiality in all interactions. Aids in furthering SCES’s mission and commitment to an inclusive environment.

Qualifications:

• Bachelor’s degree in social work, nursing, or related field strongly preferred. LPN candidates with an accredited practical nursing program and MA licensure may be considered
• Minimum 1–2 years of experience in long-term services and supports, discharge planning, community-based case management, or related field required; 2+ years preferred
• Demonstrated knowledge of long-term care systems, housing resources, and public benefit programs.
• Demonstrated ability to manage complex cases involving medical, housing, behavioral, or system-level barriers
• Must be able to work independently and collaboratively with health professionals, community agencies, service providers, and agency staff
• Strong verbal and written documentation skills with the ability to clearly reflect assessment findings, planning rationale, and case progression.
• Must be able to work with diverse populations
• Exceptional time management and organizational proficiency. 
•    Must meet both CORI/SORI and public health screening requirements.
•    Must be knowledgeable of and comfortable using Adobe and MS Word, Excel, SharePoint, and other 

   Microsoft 365 platforms. Experience with Wellsky and/or PASRR a plus.

•   Must be able to travel to the office, clients’ homes, local community agencies, and area hospital and SNFs   

  via public transportation or by car. Hybrid office/work from home schedule opportunities available. 

•    Bilingual preferred.

Physical Environment:

• Physical surroundings are comfortable with minimal exposure to injury or hazards.

Social/Psychological Conditions:

• Occasional stress due to periodic or cyclical workload pressures and deadlines. Some interruptions involved.

Physical Effort:

• Frequently sits, stands, walks, bends, reaches, and stoops throughout the day.
• Frequently lifts, pulls, pushes, and carries up to 20 lbs.
• Periodic eye strain and light ear strain.