40 hours, full time.
Adhere to all policies and procedures relative to outreach and engagement, care coordination, care management, and care transition functions and activities;
Assume responsibility for a mixed acuity case load;
Facilitate consents, gathering of clinical information (including all existing medical, behavioral health and treatment plans) and discussion with enrollee's BH and medical providers
Conduct outreach and outreach engagement activities and provide information about the benefits, design and purpose of the CP Supports
Facilitate the scheduling of and conduct the comprehensive assessment, face-to-face whenever possible and appropriate;
Identify need for interpreter service, cultural considerations, preferences, and accommodations;
Utilize person-centered framework to identify the enrollee's and/or caregivers goals, preferences, and desired level of involvement;
Develop and maintain crisis plans and communicate the individual's self-management plan
Under the direction of the clinical case manager, assist in the forming and operation of a Care Team for each engaged Enrollee
Facilitate communication among and coordinate with the Engaged Enrollee, the PCP, and other providers who serve the Engaged Enrollee
Execute the activities necessary to support the Engaged Enrollee?s Person-Centered Treatment Plan and to ensure the Engaged Enrollee has timely and coordinated access to primary, medical specialty, LTSS, and behavioral health care
Prior to an Engaged Enrollee's inpatient discharge or change in treatment setting, assist in the development of an appropriate discharge plan, in coordination with the Engaged Enrollee, the Engaged Enrollee's PCP, ACO, MCO and other providers, as appropriate.
Develop and maintain collaborative relationships with community based organizations in the Contractor's Service Area
Continuously identify and help resolve barriers to meeting goals and complying with the CP;
Facilitate enrollee referrals to resources including medical appointments as directed by the CP and conduct ongoing follow-up
Assess progress against the CP and goals and update as appropriate;
Assist enrollee in navigating the network of community based services and information
Support safe transitions in care for enrollees moving between settings
Provide temporary assistance with transportation to needed medical/BH appointments when needed while transitioning to community-based transportation, (e.g., assisting enrollee with the PT1 form).
Facilitate communication between the enrollee or designated representative and enrollee?s healthcare providers
Attend integrated rounds meeting as scheduled or as requested
Participate in supervision with LHBS BH CP clinical Care Manager
Participate in all trainings conducted or directed by LHBS
Conduct health and wellness coaching activities, offer materials in preferred language and formats when needed
Support enrollee with medication referrals and management
Ensure enrollee screening of medical conditions, identification of medical PCP, and connection to medical provider(s) as needed.
Must have the ability to follow oral and written directions as they relate to the functions listed above. Must have excellent oral, written and interpersonal communication skills to effectively interact with Division leadership, staff, and external stake holders.
Must have the ability to organize, prioritize and multi-task workload in a fast paced environment, handle confidential matters with discretion and maintain a professional demeanor. Ability and desire work with a diverse and multicultural setting.
T-About the Job
The Behavioral Health Community Partner (BHCP) program at Lahey Health Behavioral Services is a new, innovative Care Management program for MassHealth members that are part of the new Accountable Care Organization (ACO) and or a Managed Care Organization (MCO). Care Coordinators are community health workers (CHWs), health outreach workers, peer specialists, recovery coaches.
Care Coordinator performs outreach and engagement, care coordination, care management, and care transition functions and activities for individuals with high behavioral health needs and enrollees in the BH CP program. The Care Coordinator, under the direction of the Lead care coordinator and BH CP Clinical Care Manager, is a Member of the Care Team and a key contributor to the Care Planning process. The CC monitors the Members adherence and response to the Care Plan.
High school graduate or equivalent required. Bachelor's Degree from an accredited university in psychology, social work or related human services field preferred
1-3 years' experience in community-based behavioral health support program preferred.
Ability and desire work with a diverse client population.
Strong communication skills (both written and verbal)
Strong time management and organization skills
Must demonstrate good boundaries regarding confidentiality and personal relationships
Strong ability to evaluate what is needed by each individual and adjust approach accordingly.
Experience with accessing local resources and navigating mental health and/or substance abuse treatment systems.
Proficiency with electronic health record documentation or ability to complete documentation electronically is required. Working knowledge of windows operating system and standard desktop applications such as Windows and Microsoft Suite
Must be able and willing to transport enrollees served. As such, must have a valid driver's license, good driving record, and reliable vehicle.
Travel and an ability to meet persons served in a variety of outreach settings is required. Some flexible hours to accomplish outreach and engagement of enrollees at times when they are reachable; this may involve some early evening hours or later work days.