Teams at Vaya Health

Provide community outreach, education, and training on the Transitions to Community Living (TCL) program and RSVP process. Identify and resolve service barriers, coordinate care across providers and agencies, document interventions in consumer records, support DOJ reporting, and collaborate with stakeholders to facilitate transitions and diversion efforts.

Provide screenings, case management, and care coordination to divert individuals at risk of entering Adult Care Homes. Complete state-required documentation, develop community integration plans, educate members about options, coordinate services across providers, and build collaborative relationships with stakeholders. Work is field-based with travel and use of state systems.

Provide community-based transition planning and coordination for behavioral health members leaving institutional settings. Manage caseloads, develop person-centered plans, arrange housing and services, liaise with providers and stakeholders, document transitions, and perform follow-up to ensure continuity of care.