The Collaborative Bridges team is an innovative care coordination pilot program to connect individuals and families with substance abuse and mental health needs upon their discharge from hospitals and provide supportive care coordination services until linked to long term community providers or client needs are resolved. This position will educate and guide patients on the critical role of primary care providers in maintaining their overall health and well-being. Emphasize the benefits of having a dedicated healthcare professional who can offer preventive care, manage chronic conditions, and coordinate specialized treatments when necessary. Encourage patients to establish a relationship with a primary care provider within their community to ensure continuity of care, timely medical interventions, and a trusted source for health related guidance. Provide resources and support to help patients navigate the healthcare system, select an appropriate provider, and understand the value of regular check-ups in promoting long-term wellness. Will help lead initiatives aimed at improving healthcare outcomes and reducing health disparities for justice impacted populations. This role focuses on increasing access to preventive, primary, and specialty care within the community, addressing health-related social needs that impact access and overall health outcomes including chronic health conditions. Will work to enhance care integration, efficiency, and coordination across various provider types and care levels. Requires a strong commitment to health equity, strategic program development, and collaboration with healthcare and community partners to drive meaningful change. Partner with Collaborative Bridges staff to provide identified clients with comprehensive medical care in addition to any Medication Assisted Recovery or other evidence-based programs for their identified substance use disorder. Provide referrals/linkages to clients for identified needs and coordinate outreach services to community based social service agencies that address social determinates of health – e.g., employment, housing, food security, transportation, etc. Ability to be respectful of the diverse cultures of the people served and to provide culturally appropriate, competent, and individualized treatment according to each client's age, gender, race, ethnicity, and culture Engage and Educate clients for participation in treatment and other outside needed resources for all Social Determinant of Health needs� e.g., employment, housing, food security, transportation, etc. Develop and maintain relationships with community-based programs and attend linkage appointments when necessary and appropriate Conduct outreach and follow up with clients, families, and treatment providers.
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Job Type
Full-time
Career Level
Entry Level
Education Level
High school or GED