Professional I, Behavioral Health Specialist;Permanent Supportive Housing

Job Summary

Permanent Supportive Housing (PSH) is a model that combines low-barrier, affordable housing, health care, and supportive services to help individuals and families lead more stable lives. PSH typically targets people who are homeless or otherwise unstably housed, experience multiple barriers to housing, and are unable to maintain housing stability without supportive services (National Health Care for the Homeless Council).

Under the direction of the Manager, PSH, the Case Manager contributes to the PSH Care Team by providing strength-based case management services to individuals with a history of being chronically unhoused and behavioral health conditions and other psychosocial needs to promote wellness and housing stability and retention. Provides integrated care by ensuring that whole person health needs are met, including medical and behavioral healthcare, as well as substance misuse services. Uses care coordination skills with individuals, their families, and internal and external providers to ensure seamless care and facilitate linkages to community resources.

JOB DUTIES & RESPONSIBILITIES (Core Competencies)

• Engagement & Assessment

• Facilitate the client's understanding of the rationale, purpose, and procedures associated with case management services.

• Obtain relevant information from the client and meaningful collateral sources to assess the client's current situation and identify any immediate needs, including but not limited to the safety and well-being of the client in his or her natural environment.

• Administer the appropriate screening instruments to gather information and initiate the process of shared decision-making and goal setting focused on the client's strengths, needs, abilities and preferences.

• Analyze and synthesize assessment data to identify problems/opportunities to address through case management interventions.

• Establish and maintain positive therapeutic relationships with clients

• Participate in routine housing inspections

• Provide face-to-face and telephonic engagements with clients.

• Engage clients through Assertive Outreach to identify clients' wellness, needs, and service preference.

• Participate in the PSH Application Interview process

• Case Manager Clinical Proficiency

• Understand and recognize of common behavioral and physical health as well as substance misuse conditions and symptoms.

• Provide behavioral health interventions based on the client's presentation, needs, and preferences.

• Understand medical necessity in service provision.

• Understand and apply Motivational Interviewing (MI), Stages of Change, and Stage-Wise Interventions.

• Understand the use and application of risk assessments (crisis/lethality assessment).

• Proficient use of clinical supervision.

• Prepare reports as requested.

• Apply prevention measure to mitigate potential behavioral health crises.

• Assist clients in the benefit application and renewal processes.

• Provide office and property-based case management services.

• Understand Housing First and Harm Reduction Best Practices.

• Attend Property Management and PSH Team meetings.

• Provide ongoing and relevant pro-social supports and life skills training on an individual and group basis.

• Apply Evidence-Based programing to address clients' barriers to wellness and housing stability.

• Coordination, Linkage & Monitoring

• Identify and maintain information about available community resources and develop a professional network in order to meet the needs and maximize client outcomes. Provide support and assistance to clients in the community setting as related to social determinants of health including, but not limited to:

• Housing/Neighborhood/Environmental needs

• Social Supports/Community and Peer needs

• Economic Needs

• Education and Vocational Needs

• Make formal and informal referrals to service providers identified in the case management plan. Follow up on referrals placed to address any barriers clients are facing to receiving care and resources needed.

• Work with a multidisciplinary service team in collaboration with Counselors, Nurses, Physicians, and Pharmacists to achieve positive client health outcomes.

• Provide interventions for clients following a transition in care from hospitalization. Work with clients and other team members to support client's functioning in the community and reduce frequency of use of ER/hospital care wherever possible.

• Work with other members of the team to assist with closing care gaps and linking with primary care. Attends medical appointments with clients as needed.

• Identify and overcome barriers to achieving medication adherence with the client.

• Identify and overcome barriers to attending medical and behavioral health appointments, including but not limited to, transportation barriers.

• Utilize data provided to increase positive health outcomes.

• Participate in multidisciplinary team meetings.

• Develop and participate in community activities in collaboration with the PSH Care Team.

• Coordinate move-out plans in collaboration with Property Management and the PSH Care Team.

• Facilitate team-based care for clients by presenting services and providers as a unified team.

• Develop and maintain collaborative relationships with Property Management

• Participate in the move-in phase for clients

• Transport and/or accompany clients to scheduled appointments as needed.

Service Planning & Development

• With the client, review assessment and screening outcomes to prioritize needs. Translate those needs into immediate, short term and long-term service goals categories and identify the appropriate case management interventions to assist the client in meeting those goals.

• Develop a written Individualized Service Plan (ISP) that reflects assessment outcomes, prioritized and mutually agreed upon needs, measurable goals and objectives, including timeframe and case management strategies.

• Conduct ongoing monitoring activities, including contact with the client, other invested parties and service providers, to assess the effectiveness of the case plan strategies and measure progress on achieving case plan outcomes.

• Appropriately terminate case management services, to include providing reasonable notice; securing client and/or legal guardian's acknowledgement of and agreement to the case termination; and, if appropriate, effectively and efficiently transitioning the client to the next level of care.

• Co-create Housing Success Plans with clients as needed

Documentation

• Use organization's EMR system to record all relevant case management service activity and information in a clear, concise, observable/objective professional and timely manner.

• Document process, progress and outcome measurements in accordance with client's service plan, assuring a clear linkage between case documentation and service plan.

• Protect the client's right to privacy and confidentiality according to best practices in preparation for handling of records, especially regarding the communication of client information with third parties.

• Obtain written consent to release information from the client or from the client's legal guardian or ensure a release is on file prior to sharing client information.

Professional, Legal & Ethical Responsibilities:

• Ensure a complete signed and dated consent to services is on file for every client prior to providing treatment or services.

• Follow established professional codes of ethics and standards of practice to promote the best interests of the client and profession.

• Follow federal, state and other governing rules and regulations in order to promote and protect client rights.

Other Duties and Responsibilities

• Provide individualized support or care coordination of healthcare, behavioral healthcare, and non-healthcare services. Therapeutic Behavioral Services may involve collateral contacts and may be delivered in all settings that meet the needs of the individual client.

• Provide ongoing communication to client, healthcare teams, and client's support network to ensure follow-up and coordinated treatment.

• Perform other related duties as assigned.

Job Qualifications

Must have:

• High school diploma with 3 years case management or care coordination experience.

• A valid driver license in the state of Ohio, with access to an insured vehicle for client transportation.

• The ability and desire to work closely with other team members.

• The ability to form effective therapeutic relationships to engage clients in the mutual assessment of problems and goal setting and to help coordinate care plans from initial contact through end of service.

Preferred:

• A Bachelor's degree in Social Work, Psychology, or a mental health related field. If in a related field, must have two years care coordination or case management experience.

• Prior experience working with SPMI adults.

• Using creativity and a drive for results, act as a liaison for the client to receive community resources.

• A working knowledge of the stages of growth and development and family dynamics.

• The ability to understand and accept a team approach to service delivery, and agency and program philosophy and goals.

• An active Community Health Worker certificate

Physical Demands/Work Environment

This job operates in a professional office environment and the community. This role routinely uses standard office equipment. While performing the duties of this job, the employee is regularly required to speak and hear. The employee is frequently required to sit for extended periods of time, stand, walk, use hands and fingers, and reach with hands and arms. Travel within the Cleveland area as needed for training and technical assistance. In addition, community travel to satisfy case management needs for clients. Employee will use non-violent crisis intervention techniques to de-escalate a client.

About The Centers

The Centers fights for equity by healing, teaching, and inspiring individuals and families to reach their full potential. We provide health, family, and workforce services at 11 locations throughout Greater Cleveland, creating life-changing solutions for people to lead healthier and more successful lives. We strive to be an equitable, anti-racist, and service-oriented workplace that pioneers and co-creates solutions while fostering an inclusive community where our team members thrive.

Wellbeing and Benefits

Providing quality benefits to our staff is important to us. Just as important is our staff's well-being. That's why we offer a number of choices to meet the different needs of our staff.

• Choice of medical and dental plans

• Health Savings Account

• Flexible Spending Account for Health and Dependent Care

• Vision

• Support for continuing education and credential renewal

• Life Insurance

• Retirement Savings (401k) with a company contribution

• 457(b) Savings

• Mental Health Support

• Employee Assistance Program

• Calm Subscription

• Short and Longterm Disability

The Centers is an Equal Opportunity Employer and all qualified applicants will receive consideration for employment without regard to age, race, color, religion, sex, sexual orientation, gender identity or expression, national origin, disability status, protected veteran status, or any other characteristic protected by law.

Other details

• Job Family Behavioral Health

• Pay Type Hourly

• Min Hiring Rate $20.00

• Max Hiring Rate $24.30

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• Cleveland, OH, USA