Care Coordinator

Education, training, experience and licensing

Education

· Masters degree from an accredited university or college with a major in counseling, social work, psychology, or a related human services field and two years full time or equivalent experience working with adults and children at risk is preferred.

· Bachelors with two years experience can be accepted.

Experience

· Minimum of two (2) years full time or equivalent experience working with adults and children at risk is preferred.

Key job responsibilities

· Provides time-limited care coordination for identified individuals using a combination of internal utilization reviews and NBH (NeuroBehavioral Hospitals) in collaboration with SEFBHN (Southeast Florida Behavioral Health Network) high-utilizer recommendations.

· Responsible for the coordination of services until the individual is adequately connected to the care that meets their needs and progress towards the goals of Care Coordination are achieved.

· Engages with Persons Served and Their Natural Support(s)

· Ensures individuals are engaged in their current setting (e.g., crisis stabilization unit (CSU), SMHTF, homeless shelter, detoxification unit, addiction receiving facility, etc.) to establish a warm hand-off.

· Works with unit supervisors to ensure frequent contact is maintained with identified individuals, ranging from daily to a minimum of three times per week, for at least the first 30 days of services, for those individuals who agree to receive care coordination services. If the individual refuses care coordination services or they are not responding to the attempts made, the Care Manager ensures the engagement attempts are recorded in the individual’s clinical record.

· Ensures that an internal process is in place that allows for on call services to be available 24hours, seven days a week.

· Standardized Assessment of Level of Care Determination Process

· Promotes the use of a standardized level of care tools and assessments to identify service needs and choice of the individual served in Care Coordination. (i.e. the Level of Care Utilization System (LOCUS) or the American Society of Addiction Medicine (ASAM) Criteria.

· Models, coaches, and supports shared decision-making in care planning and service determination with the individual and family members (where applicable) and emphasizes self-management, recovery and wellness, including transition to community based services and/or supports.

· Promotes a recovery oriented perspective that the individuals served and their family members are the driver of goals on the Care Plan.

· Helps develop internal protocols for use of the Recovery Oriented Care Coordination (ROCC) module to promote shared accountability.

· Implements procedures and protocols in collaboration with NBH and SEFBHN that support ROCC Interdisciplinary Care Team (ICT) Staffing.

· Works with NBH and SEFBHN to develop diversion strategies to prevent individuals who can be effectively treated in the community from entering SMHTFs.

· Engages NBH in collaboration with SEFBHN when technical assistance is needed to overcome or eliminate system barriers.

· Shares newly identified community-based services/resources with NBH and SEFBHN and ensures the list is kept current.

· Takes a leadership role in assessing internal organizational culture and finds ways to incorporate the core values and competencies of Care Coordination into daily practice.

· Tracks unmet service needs and gaps and provides feedback to NBH and SEFBHN.

· Monitors access to psychiatric services to ensure that individuals who require medications are linked to psychiatric services within seven days of discharge from higher levels of care. If no appointments are available, this is documented in the medical record and NBH and SEFBHN are notified. If the individual refuses services, this is documented in the record.

· Ensures internal capacity to assess individuals for eligibility of Supplemental Security Income (SSI), Social Security Disability Insurance (SSDI), Veteran’s Administration benefits, housing benefits, and public benefits, and assist them in obtaining eligible benefits, including the use of SOAR when assessing for SSI and SSDI.

· Monitors how effectively internal staff has incorporated into treatment plans the values, preferences, beliefs, culture, and identity of the individual served, and their community when providing care coordination.

· Ensures there are internal protocols for meeting the linguistic needs of the individuals served.

· Recommends ways that internal quality assurance protocols can address cultural and linguistic competence.

· Tracks individuals served through Care Coordination for improved outcomes in the following areas:

Readmission rates for individuals in acute care settings;

Length of time between acute care admissions;

Length of time an individual waits for admission to a SMHTF;

Length of time an individual waits for discharge from a SMHTF

Length of time from an acute care setting/SMHTF discharge to linkage to services in the community