Habilitation Coordinator

Full COVID-19 vaccination is an essential requirement of this role, unless individual is approved for a reasonable accommodation based on disability, medical condition, or religious belief that prevents them from being vaccinated. MHMR will adhere to all federal, state and local regulations as well as all client requirements and will obtain necessary proof of vaccination prior to employment to ensure compliance

Pay is determined by relevant experience, work history, education and internal equities. As part of our Diversity, Equity, and Inclusion practices, MHMR offers the maximum compensation for candidates based on their experience, education and internal equities of the agency. This practice removes biases in compensation and assist hires and/or promotions on pay equity in their appropriate position(s) at MHMR.

The average rate for this position is… 24.04

I) Job Purpose

The Habilitation Coordinator (HC) are field based staff and are expected to comply with the Guidelines for Field Based Staff that are established. One of the goals of DS Services is to provide the people we serve with seamless consumer driven services and supports. Towards this end, Habilitation Coordinator (HC) are expected to recognize their responsibility to collaborate with each other, proactively communicate within and across programs, services, and supports, and are knowledgeable about the array of services and supports available in the community.

Each person receiving services in the PASRR (Pre-Admission Screening Resident Review) Program in Tarrant County will have a single identified staff, called a Habilitation Coordinator (HC).  The HC will assist the person in identifying and articulating his/her priority outcomes, personal goals and hopes for the future as well as his/her request and need for services and supports.  The HC will elicit the person’s feedback and coordinate the services and supports needed to address the person’s personal goals and desired outcomes as identified through the person’s Habilitation Service Plan (HSP), Individual Profile-Nursing Facility and Habilitative Assessment. Through continued discovery process, the HC will gather the person’s feedback and coordinate the services and supports as that person’s wants and needs change. The HC is responsible for monitoring services based on the HSP. The HC is responsible for developing the person’s Habilitative Assessment to help guide the decisions identifying which specialized services are best to support the person in accomplishing his or her outcomes. The HC is responsible for communicating concerns that are discovered during monitoring to the guardian and other members of the team, as deemed necessary, in addition to the Program Manager. The HC is responsible for attempting to solve problems that are identified.

The Habilitation Coordinator (HC) will be responsible for providing community living options for individuals in nursing facilities, and assisting persons wanting to transition out of a nursing facility.  These activities are information or educational and may include family to family, peer to peer, benefits about community living, facilitating such visits, in such setting, offering opportunities to meet with individuals who are living, working, and receiving services in integrated settings, with their families, and with community providers, coordinating with providers. 

II) Essential Functions

With limited supervision provides on-going services to assist persons with developmental disabilities or related conditions: in developing their initial and ongoing Habilitation Service Plan (HSP), Individual Profile-Nursing Facility, and Habilitation Assessment; and informed choice regarding community living options and specialized services.  The work requires use of initiative and independent judgment. The work requires aggressive intervention in the community and interaction and cooperation with other internal departments with MHMRTC as well as HHCS, nursing facilities, community providers and other outside organizations, and community resources.  Frequent in –person, long-term contact with individuals assigned, their families and service providers are required. The work also entails timely completion of required documentation.

Habilitation Coordinators (HC) specific protocol and procedures: Participate in the IDT/SPT, offer PASRR services, and if accepted, then complete the Habilitative Assessment, complete Community Living Options, the Habilitation Service Plan (HSP), Individual Profile- Nursing Facility, Habilitation Coordination Authorization Request, PASRR Comprehensive Service Plan (PCSP), initiate IDD Habilitative Specialized Services, and review assessments such as, but not limited to the NF Comprehensive Care plan.  

The Habilitation Coordinators (HC) will receive ongoing training on the specific protocol and procedures, as well as, the development and monitoring process of the Habilitation Service Plan (HSP), Individual Profile-Nursing Facility, and Habilitative Assessment; the development of the initial, update, and renewal of these plans; crisis intervention activities; service planning and coordination; and monitoring.  The Habilitation Coordinators (HC) will maintain current and up to date knowledge on Health and Human Services Commission (HHSC) rules and regulations as well as MHMR TARRANT policies and procedures.

1. PRINCIPLE RESPONSIBILITIES:

A) Validate the suspected diagnosis of Intellectual Disability (ID) or a Developmental Disability (DD) also referred to as related conditions. As assigned out complete PASRR Evaluations (PE) on indicated individuals. The Habilitation Coordinator has a total of 7 days, from the date of notification, to initiate, complete and submit the PE into the LTC Online Portal.

Performance Requirement(s)

1. Initiate the PE within 72 hours of notification from the LTC Online Portal. (In the case of

Portal malfunction, the notification for requesting a PE may come from the Nursing

Facility (NF).)

2. Complete the PE within 5 days of notification from the LTC Online Portal.

3. Submit the PE within 7 days of notification from the LTC Online Portal.

4. Document in the database all needed information within the Service Coordination Guidelines timeframes.

B) Participate in person for IDT/SPT’s. Facilitating the Habilitation Coordination Planning Process, the discovery process; identifying and planning to mitigate risk for each person, begin the individual assessment process, gathering additional information, facilitate SPT meeting and in the overall development of the Habilitation Service Plan (HSP) and Individual Profile-Nursing Facility.

Performance Standards

1. Participate in a discovery process with the person and others identified by the person that results in identification of personal outcomes or personal goals, barriers to achieving those goals, and identification of services and supports to meet goals.

2. Coordinate and facilitate Habilitation Service Plan (HSP), Individual Profile-Nursing Facility, Community Living Options (CLO), and Habilitative Assessment for each individual within timelines outlined in Rules and Handbooks.

3. Develop narrative results in the desired plan for each person enrolled in services.

4. Assure that all processes and service planning respect the needs, requests and preferences of the person and occur in a timely manner and are directed towards the achievement of the person’s goals and desired outcomes.  

5. Address Community Living Options (CLO) with the person and LAR by offering educational opportunities and informational activities; and providing information about the range of community living services, supports, and alternatives, identifying the services and supports the designated resident will need to live in the community, and identifying and addressing barriers to community living in accordance with HHSC's IDD PASRR Handbook and using HHSC materials.

6. Assure that anytime barriers to achieving personal outcomes are identified and communicated to the person and service provider.

7. Assist in the coordination and development of the PCSP, based on the results of the HSP/Individual Profile-Nursing Facility for each individual served and that a review and indication of acceptance or refusal is noted in the CARE and TMHP database.

8. Ensures that face to face visits occurs at a minimum of monthly or more frequently, if needed. 

9. Responsible for convening and facilitating SPT (Service Planning Team) meetings and the NF comprehensive Care plan at a minimum every 90 days or after recent hospitalizations, emergency department contacts, increased physicians’ visits, other crises, or as needed for individuals transitioning into the community. 

10. Coordinating with the NF in accessing medical, social, educational, and other appropriate services and supports that will help an individual achieve a quality of life acceptable to the individual and LAR on the individual's behalf.

11. Review and monitor identified risk factors, such as choking, falling and skin breakdown, and report to the proper authority (e.g., HHS Complaint and Incident Intake) if they are not addressed.

12. Review all available assessments to determine the individual’s need for specialized services.

13. Make timely referrals, service changes, and revisions to the HSP, as needed.

14. Monitor to determine if the individual is provided opportunities for engaging in integrated activities with residents of the NF who do not have ID or DD; and in community settings with people who do not have a disability.

C) Monitor the progress of desired outcomes for each person served. Schedule and facilitate planning/linking activities and conferences as needed to address issues and make revisions to the individual’s Habilitation Service Plan (HSP) and Individual Profile- Nursing Facility as indicated by need.

Performance Requirement(s):

1. Monitor services provided to each individual monthly with an eye towards how effective and appropriate current services are towards helping the individual meet his/her Outcomes.

2. Elicit feedback from each person served and assure that any modifications in their service plan are coordinated as that person’s wants and needs change.

3. Complete a review of progress or lack of progress towards achievement for each outcome identified in the Habilitation Service Plan (HSP) and Individual Profile-Nursing Facility at least quarterly.

4. Assure that the Habilitation Service Plan (HSP) and Individual Profile-Nursing Facility updates are completed in a timely manner and are based on consultation with the person being served and, as appropriate, their family/guardian and provider.

5. Ensures that individuals are monitored within the frequency established by Best Practice and in consultation with the Program Manager 100% of the time. 

D) Complete all required documentation and ensure that it meets the minimum Medicaid requirements.

Performance Requirement(s):

1. Assure that each individual served has a current Habilitation Service Plan (HSP), Individual Profile-Nursing Facility, Community Living Options (CLO), and Habilitative Assessment 100% if the time.

2. Assure Community Living Options (CLOs), are presented at the first face-to-face meeting with the individual and LAR following HC assignment; at least every six months thereafter as long as the individual continues to reside at a nursing facility; and at any time the individual/LAR wishes to review community living options; and uses the CLO educational materials developed by the Texas Health and Human Services (HHS). 

a. For and individual who refuse who refuses Service Coordination, the ECC SC must ensure the individual/LAR receive information about the range of community living options (CLO) using HHSC materials during the individual’s initial meeting with a Service Coordinator and at least annually thereafter, documenting the discussion on the Community Living Options form.

3. Assure that all requited documentation is in the chart for each individual served.

4. Assure timely completion of all documentation related to Targeted Case Management and Administrative Claiming.

E) Build effective relationships with all stakeholders on behalf of the person being served.

Performance Requirement(s):

1. Facilitate coordination between an individual’s service planning team, HSP planning team, and the nursing facility’s plan of care, if applicable.

2. Assure that the individual, guardian, nursing facility and other SPT members has a copy of the most habilitation packet (HSP).

3. Assure that the Nursing Facility, SPT members, and guardian are aware of concerns that are discovered as a part of monitoring the person.

4. Assist in securing generic resources as needed.

5. Assure that pertinent information is reported to the Program Manager/Assistant Director/Director as needed.

6. Assure that all necessary/required information is forwarded to nursing facilities/providers in a timely manner.

7. Be phone accessible and respond to all calls in a timely manner as outlined in the Guidelines for Field Based Staff. 

8. Properly notify program manager/director and or designee of emergency situations. 

F) Perform other related job duties or responsibilities as requested or required, whether or not specifically mentioned in the job description.

1. Exhibits a willingness to assume additional duties; seeks the guidance of supervisor prior to beginning an unfamiliar assignment. 

G) Meet performance timelines and participates in Divisional, Departmental and Agency Meetings.

Performance Standards

1. Completes and submits travel vouchers/reimbursement forms according to agency procedures 100% of the time.  

2. Maintains a high attendance record and notifies Program Supervisor of intentions to be absent by start of workday.

3. Completes all required annual refresher training 100% of the time. 

4. Attends all departmental meetings on a regular basis and meetings requested by your Program Manager. 

5. Exhibits strong customer service skills by:

6. Receiving a limited number of verified consumer complaints (less than 4 annually) related to communication or actions.

7. Being focused on providing quality and timely services and information to all consumers served in a consumer-friendly manner.

8. Working with fellow employees as well as community contacts in a professional manner.

9. Complete all organizational required training within first 60 days of hire. 

10. Attend seminars, workshops, etc. to maintain up to date information regarding all issues related to service coordination. 

H) Provides support for program goals by working as a team member

Performance Requirement(s):

1. Reports to work and back from lunch punctually.

2. Maintains good interpersonal relations with team members and outside staff.

3. Maintains good attendance record.

I) Serves as a contributing member of the administrative support team

Performance Requirement(s):

9. Identifies problems and issues needing attention and develops possible solutions to those problems.

10. Communicates well with both program staff and consumers.

11. Assists with any additional project as the Supervisor deems necessary.

12. Ensures all special assignments or instructions given by the Supervisor or Director are carried out accurately and on a timely basis.

13. Exhibits a willingness to assume additional duties; seeks the guidance of supervisor prior to beginning an unfamiliar assignment.

J) Performance standards are performed as applicable with MHMR’s We CARE values “We Connect People in Our Community.  We Provide Access to Services.  We Link People to Resources.  We Empower People.”

K) Performs other job duties or responsibilities as requested or assigned.

III) Knowledge of Laws, Policies/Procedures, Skills, Education, and Abilities

a. MHMR Tarrant operating procedures

b. HHCS rules and regulations

c. HHSC-developed training related to PASRR

d. Person-Centered thinking training

e. Ability to work independently

f. Ability to communicate with the communication board

g. Ability to produce quality work in stressful situations; tackle tough assignments.

h. Possess independent decision-making skills.

i. Ability to maintain professional interpersonal working relationships.

j. Ability to maintain confidential files and matter.

k. Ability to independently plan and organize work.

l. Ability to establish and maintain effective working relations with Supervisor, co-workers, and staff working for outside agencies.

m. Ability to maintain self-control.

n. Ability to prioritize workload and be self-directed. 

o. Complies with the rules governing service coordination for an individual with an intellectual disability (40 Tex. Admin. Code, Chapter 2, Local Authority Responsibilities, Subchapter L, Service Coordination for Individuals with an Intellectual Disability).

IV) Internal & External Customer Service

a. Outside 

b. Inside 

c. Excessive / Intermittent noise 

d. Work closely with others

e. Potential occupational exposure to blood, or other potentially infectious materials. 

f. This position requires internal and external contacts (community resources and organizations, clients, families and general public, public/private providers, state office staff, auditors, accreditation organizations, other state programs like DFPS, TSHS, TDHS, etc.)  The employee will provide these using written and/or verbal skills, in person and/or by telephone.

g. Longer or irregular work hours

h. Poor hygiene of clients and/or families

V) Travel

a. This position requires driving between locations as an essential function of work. Work related training maybe at varied locations and employee is responsible for getting to and from the training location This position requires driving to and from locations for work and/and may require overnight traveling. Employees are required to have a license in good standing and be able to be covered by agency liability insurance. If personal vehicle is utilized for work travel, then maintaining personal auto insurance coverage is required.

b. This position may require temporarily or permanent re-assignment to any of the DS facilities as determined by the program needs.

Lifting requirement up to 15 #

Job Requirements:

Required Education

Bachelor’s or Advanced degree

Defined Education

Social, behavioral or human service field

Required Years’ Experience

1-year experience (working directly with individuals with IDD)

Preferences 

QIDP Qualified

Special Courses 

As defined by HHSC to provide Habilitation Coordination and Enhanced Service Coordination.

Required License

Valid Texas Driver’s License

Required Supervisory Experience

N/A

Testing Requirements
Pre-employment tests including drug and TB Screening, Physical Exam including balance and lift test.
Satori Alternatives to Managing Aggression (SAMA) Protection

Lifting Requirements
15 to 44 Pounds

All staff are required to participate in agency Emergency Preparedness and Environmental Safety programs and may be assigned by their departments as a key/essential staff level function during critical events or for the purpose of sustaining business continuity.

This position may require temporary or permanent re-assignment to any MHMR Tarrant facility as determined by program needs and /or the Division/Director.

Assigned work hours may change as the needs of the agency change.

The functional Title of this position may change as the needs of the agency change.

All work will be complete within the scheduled work hours.  All non-exempt (hourly) employee are expected to clock In and out for each work shift, no work done should be done off the clock.

Prior approval from supervisor is required for all Paid Time Off (PTO) and Overtime.

MHMR reserves the tight to change, and to or eliminate a position as it deems appropriate.

Employment is at will, as well as agency needs may change.

Agency dress code is to be followed at all times.

Physical on-site presence, including regular attendance and punctuality is an essential function of this position.  Any change or adjustments to your assigned work schedule or shift hours must be approved by your supervisor in advance.

Our Benefits:

All staff are required to participate in agency Emergency Preparedness and Environmental Safety programs and may be assigned by their departments as a key/essential staff level function during critical events or for the purpose of sustaining business continuity.

This position may require temporary or permanent re-assignment to any MHMR Tarrant facility as determined by program needs and /or the Division/Director.

Assigned work hours may change as the needs of the agency change.

The functional Title of this position may change as the needs of the agency change.

All work will be complete within the scheduled work hours.  All non-exempt (hourly) employee are expected to clock In and out for each work shift, no work done should be done off the clock.

Prior approval from supervisor is required for all Paid Time Off (PTO) and Overtime.

MHMR reserves the tight to change, and to or eliminate a position as it deems appropriate.

Employment is at will, as well as agency needs may change.

Agency dress code is to be followed at all times.

Physical on-site presence, including regular attendance and punctuality is an essential function of this position.  Any change or adjustments to your assigned work schedule or shift hours must be approved by your supervisor in advance.

Our Benefits:

Our total rewards program offers benefits* to full time employees beginning 1st of the month following hire date including but not limited to:

• Comprehensive healthcare options (Medical, Dental, and Vision)

• Life insurance and additional supplemental accident and hospitalization plans

• 401a match and 457 deferred compensation plans

• Paid vacation and holidays; varied flexible work environment locations

• Annual tuition reimbursement program

• Student Loan Forgiveness

• Professional development programs and training

• And more…..

Insurance eligibility:

• Full time employees begin 1st of the month following hire date

• Market driven positions (full time or part time) begin immediately after hire date

• Select part time market driven positions are eligible for most insurance plans

• Substitute status jobs are not eligible for benefits

For more information, click https://www.mhmrtarrant.org/benefits/

Additional Information
*MHMR of Tarrant County (“MHMR”) and its affiliates and subsidiaries have an internal recruiting department. MHMR may supplement that internal capability from time to time with assistance from temporary staffing agencies, placement services, and professional recruiters herein after referred to collectively as “Recruiters"). Recruiters are hereby specifically directed NOT to contact MHMR employees directly in an attempt to present candidates – MHMR recruiting team or other authorized MHMR personnel must present ALL candidates to hiring managers. For more information please visit our website www.mhmrtc.org