CTI Transition Coach

Critical Time Intervention (CTI) is an evidence-based care transitions approach that has been shown to drastically reduce psychiatric inpatient and emergency department readmission rates. Developed by practitioners and academics it offers staff members the training and tools to impact lives combined with the flexibility to meet people where they are and develop customized and targeted plans. Youll support up to 20 individuals over a 9-month care transition period helping them build sustainable links to long-term services and community support.

Your Responsibilities Will Include:

• Pre-CTI: Engage with individuals before discharge to build trust and prepare for transition
• Phase 1 (First Month): Be there on discharge day and help clients connect to housing benefits and mental health services
• Phase 2: Support clients and their networks encouraging independence and responsibility
• Phase 3: Ensure long-term support systems are in place and working well before graduation
• Document everything in the electronic health record (EHR) to track outcomes and progress

Guiding Principles

• Critical Time Intervention (CTI) is a short-term intervention with the primary focus on connecting people to long-term support (both clinical and social).
• The CTI worker is a combination of organizer of resources and direct support and works in concert with other care delivery and clinical teams.
• Success is measured by reduction in avoidable hospitalization and meaningful connection to community providers (measured by kept appointments).

• Bachelors degree in social work psychology education or related field and 1 years experience
• DHHS approval is required if candidate has only an Associate degree or High School Diploma with appropriate work experience.

Recommended

• Experience with behavioral health or social determinants of health (SDoH) systems including case management or delivery of clinical intervention.
• Experience with social determinants of health-related programs including but not limited to housing employment food insecurity and entitlements.
• Understanding of NH systems of care with experience working between systems. Comfort with technology and reporting systems with the understanding that use of the agencys electronic record is compulsory.