Care Transitions Specialist
4 weeks ago
Hours Per Week: 35
Duties and Responsibilities:
- Under the direction of a Health Home Supervisor, JASA's Health Home Plus Care Transitions Specialist is responsible for the provision of intensive case management, outreach, care coordination, and crisis intervention for a caseload of mentally and/or physically impaired clients. In accordance with the standards of the social work profession, agency policies, and requirements of the funding source, the role requires key skills and knowledge for serving high need individuals with Serious Mental Illness (SMI).
- The Health Home Plus Care Transitions Specialist will perform the duties listed below:
- Conduct appropriate screening and either perform or arrange for more detailed assessments when needed (e.g., high-risk substance use or mental health related indicators, harm to self/others, abuse/neglect and domestic violence). Conduct triage for emergency intervention; ascertains short-term needs; and provides accurate and appropriate information and referral services to clients, families, and collaterals.
- Provide in-home, in-office, and community assessments of the social and emotional needs of the adult client and his/her family; utilize prescribed standardized Health Home assessment instruments; and secures appropriate assistance of other social work and/or professional consultants.
- Develop and implement written case plans to provide a full range of social services for older adult clients and family, including:
- Provides individual and family counseling and guidance to resolve problems of the client(s) and family.
- Prepares and disseminates appropriate information to clients and collaterals regarding the normal physical, social, and psychological development of individuals, challenges to functioning presented by conditions of impairment, disease, social stresses and dysfunction, and suggests methods used to cope and preserve individual functioning and autonomy.
- Prepares specific information about health, welfare, education and recreation services available to serve the older client.
- Screens client eligibility and applications for appropriate benefits and entitlement.
- Arranges for direct provision of services such as homemaker, home health aide, public assistance, Medicare, Medicaid, emergency cash relief, legal aid, protective services, vocational placement, medical and psychiatric examination and therapy, housing, etc.
- Evaluates clients' capacity to manage their own affairs and protect themselves from financial exploitation.
- Coordinates care with medical and mental health providers; identifies providers, assists with securing appointments, participates in care plan meetings, etc.
- Refer to, and maintain a cooperative relationship with, other community agencies to meet the needs of clients.
- Conduct ongoing monthly in-home visits to evaluate client functioning, monitor risk, assess the status of current services, and update and revise the case plan; seeks appropriate guidance from the supervisor in situations requiring clarification and consultation.
- Extended Hours and Emergency Schedules:
- May be called upon to respond to an after hours client crisis.
- Supervise community aides, interns and volunteers.
- Represent and interpret the agency at community conferences and meetings.
- Participate in training and unit meetings.
- Complete required case records, reports and statistics within mandated time frames, utilizing required Health Home dashboard and JASA EHR systems.
- Handles special assignments and duties as assigned.
- Create and leverage relationships with critical behavioral health service providers to plan and coordinate care management needs for high-need SMI individuals including:
- Navigating the mental health service system-including ability to make referrals to mental health housing services, crisis intervention/ diversion, peer support services
- Knowledge of the behavioral health managed care benefit package and coordinating care with MCOs (e.g., for HARP members)
- Collaborates with inpatient staff and MCO (as applicable) to affect successful transitions out of inpatient or institutional settings
- Addressing the quality, adequacy and continuity of services to ensure appropriate support for individuals' mental health and psychosocial needs.
- Maintain engagement with individuals who are often disengaged from care, have difficulty adhering to treatment recommendations, or have a history of homelessness, criminal justice involvement, first-episode psychosis and transition-age youth. Key skills and practices to engage high-need SMI individuals include but are not limited to:
- Motivational Interviewing
- Suicide Prevention
- Risk Screening
- Trauma Informed Care
- Person-centered care planning and interventions
- Recovery-Oriented Approaches (e.g., Wellness Recovery Action Plans)
Education and Experience:
- International Medical Graduate (degree)
- A Bachelor's degree in one of the qualifying fields below and two (2) years of Experience; OR (Qualifying fields include education degrees featuring a major or concentration in: social work, psychology, nursing, rehabilitation, education, occupational therapy, physical therapy, recreation or recreation therapy, counseling, community mental health, child and family studies, sociology, speech and hearing or other human services field.)
- A Credentialed Alcoholism and Substance Abuse Counselor (CASAC) and two (2) years of Experience; OR A Bachelor's degree or higher in ANY field with either: three (3) years
- Experience, or two (2) years of experience as a Health Home care manager
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