Hospital to Home Team and Roles

The Program Director is a Licensed Master Level Clinician with oversight of case management, educational, and residential services to ensure cohesion and integration of services.

The Case Managers carry a mixed caseload of residential and community youth and will remain with the youth/caregiver for the entirety of the case. Case managers are integral to creating the eco-map of what is in place and creating the referrals and warm handoffs to service providers to fill in the gaps.

The Educational and Vocational Specialist works to maintain the youth and caregivers’ connection with the community educational/vocational programs in place and will help create new opportunities as needed.

The Administrative Assistant is the key point of contact for caregivers, providers, and community partners. They provide day-to-day support to the H2H team by managing scheduling, coordinating referrals, and maintaining accurate records in compliance with confidentiality regulations.

The Clinician serves as a supplemental service and support or as a bridge to provide individual and caregiver sessions while a community provider/program is accessed and established. This clinician will provide individual/caregiver work but can also program and provide groups (for example, a Dialectical Behavioral Therapy [DBT] group at the residential site.)

The Nurse reviews and recommends/connects to medical providers and provides education to youth and caregivers to promote physical well-being.

The Behavior Intervention Specialist assesses and creates behavior intervention plans to ensure a targeted consistent response in shaping behaviors both in residential care and at home; they will share these plans with educational/vocational providers.

The Recreational Therapist provides recreational plans and programming for youth while in the residential setting and provides resources to youth and caregivers in the community.

The Family Peer Advocate works with caregivers in the home, residential, and community settings to help families execute their voice in planning and goals, and to lend their expertise in lived experiences.

The Youth Peer Advocate works with the youth in the home, residential, and community with the goal of inspiring hope and motivation, while supporting youth voice and choice to communicate effectively with others, advocate for their needs, and achieving their goals.

The Team Leader oversees the Transitional Residential Setting of H2H to ensure all youth have proper supervision, that a therapeutic model is being followed, and provide support to residential counselors who will be directly supervising and working with youth to achieve their goals while staying the residential component of H2H.

The Assistant Team Leader supports the Team Leader and Residential staff.

The Residential Counselors work directly with youth to ensure they are supervising youth appropriately 24/7 and providing therapeutic crisis intervention techniques to ensure safety at all times.