Under the supervision of the Director of Community Nursing at The People Concern (in collaboration with appointed hospital staff), The Regional Hospital Liaison will:

  1. Establish and Maintain Relationships with Partners:
    1. Establish and maintain positive relationships with hospital partners including staff in the emergency rooms, social work, discharge planning, and any onsite homeless patient navigators in order to educate staff on the services available to this population and resources available within the Community Resources binder. 
    2. Coordinate directly between hospitals and community providers, fostering relationships between organizations and facilitate transitions of care for individuals experiencing homelessness and coordinate discharge needs for homeless patients including obtaining medications and clothing for homeless patients and helping to arrange transportation as needed.
    3. Maintain a cooperative relationship among care teams with both inpatient and Emergency Department staff by communicating information, responding to requests, building rapport, participating in team problem-solving efforts.
    4. In conjunction with Hospital staff, maintain the Community Resources binder on services available for the homeless population.
    5. Convene hospital partners and patient navigators for case conferencing and problem-solving and encourage hospital participation in relevant community collaboration meetings such as CES meetings.
    6. Coordinate and improve follow-up care and services for homeless patients by assessing their needs and schedule follow-up medical appointments and connecting patients to a PCP as appropriate.
  1. Assessment, Referral, and Service Connection
    1. Conduct CES Triage Tools for high-acuity frequent hospital users when scheduled in advance and connect to CES staff who can administer the full SPDAT assessment tool.
    2. Use HMIS for service reconnections, including Outreach, Interim Housing, Housing Navigation.
    3. Provide updates to Outreach staff whose clients are admitted to a hospital.
    4. Connect or reconnect patients to a medical home as appropriate.
    5. Refer to CES Access Sites/Access Centers for assessment/service connection when appropriate
    6. Identify high-acuity frequent users for eligibility assessment for Health Homes Program (HHP).
    7. Actively collaborate with hospital patient navigators/social workers/discharge planners to:
      1. Support the discharge planning process by providing information and helping to facilitate access to community-based providers
      2. Facilitate warm hand-offs for patients from patient navigators or hospitals to CES staff and community partners
      3. Create housing plans for high acuity “frequent flyers” who have not engaged with homeless services
      4. Support accessing higher level of care, i.e. Adult Residential Facilities, Skilled Nursing Facilities, etc.; serve as a point of contact during the referral and placement process
    8. Maintain database and detail-oriented documentation of the services provided for each patient
    9. Be thoroughly familiar with the policies and procedures guiding the work of this program and perform job functions in line with these policies and procedures.
  1. Tracking/Data Management:
  • Document referrals thoroughly and in a timely manner
  • Document processes and best practices for shared learning
  • Identify data gaps and propose potential solutions
  • Ensure all team members are collecting and reporting data
  • Compile monthly program data
  • Prepare data and reports for submission to the funder
  1. Training and Education: 
  1. Educate hospitals’ patient navigators, social workers and discharge planners on:
    • Problem-solving/diversion of homeless patients out of the ED
    • Accessing the services and resources of the homeless services
    • HHP eligibility and HHP screening form
    • Using the Universal Interim Housing Referral Form
    • Completing verification of homelessness forms when needed for program referral/entry
  2. Provide Technical Assistance / “on-call support” to hospital patient navigators, social workers/discharge planners regarding homeless services
  3. Identify and provide additional training as needed
  1. Staff Supervision:  
    1. Recruit, hire and supervise 3 Hospital Liaisons
    2. Conduct monthly supervision and annual performance evaluations
    3. Provide training and support to staff in their positions
    4. Conduct periodic team meetings to discuss best practices, issues, and concerns and troubleshoot problems
  1. Other Responsibilities:
    1. Participate in all safety programs and training required by the hospitals and TPC. 
    2. Utilizing a harm reduction model, trauma-informed care and client-centered philosophies to improve the follow-up care and services provided to homeless patients and connecting them with the appropriate resources.
    3. Maintain strict confidentiality and privacy practices and share information, as appropriate and legally allowed, to coordinate patient care.
    4. Maintain a safe and clean working environment.
    5. Other duties as assigned

  • Demonstrate the ability to interface with community agencies and hospital staff.
  • Experience working as part of a health care team preferred.
  • Minimum of one (1) year of experience working with homeless and/or underserved populations.
  • Knowledge of healthcare systems.
  • Significant experience working with persons experiencing homelessness and having complex needs, conducting assessments of general patient information, developing short-term care plans and providing necessary interventions identified during assessment.
  • Previous experience working with persons experiencing severe and persistent mental illness and substance abuse.
  • Able to work some evenings and weekends.
  • Strong Computer skills including MS Office Suite.
  • Ability to work well as part of an interdisciplinary team.
  • Excellent verbal and written communication skills.
  • Excellent charting/documentation skills and data collection.
  • Passion for and commitment to working with underserved and indigent populations.
  • Ability to work well with a culturally diverse clientele, including LGBTQ individuals and those living with disabilities, serious mental illness and substance use disorders.
  • Skilled in non-violent crisis intervention.
  • Ability to self-motivate, multi-task and be flexible in a fast-paced environment.
  • Must successfully pass fingerprinting and background checks before the start of employment.
Education Requirements:
  • College degree required.
  • Bilingual (Spanish/English) preferred.
  • Valid CA Driver’s License and car required for travel when needed to carry out job-related duties.

Department: Turning Point
This is a non-management position
This is a full time position

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