Licensed Professional Mental Health Counselor (Mental Health Treatment Coordinator)

Department of Veterans Affairs•Spokane, WA

61d•Onsite

About The Position

This position is located within the Behavioral Health Interdisciplinary Team (BHIP) under the Behavioral Health Service at the Mann-Grandstaff VA Medical Center in Spokane, WA. The incumbent serves in the role of the Mental Health Treatment Coordinator (MHTC), also referred to as Care Coordinator. Duties will vary based on grade. At the GS-11 full performance level of this assignment, the incumbent serves in the role of the Mental Health Treatment Coordinator (MHTC), also referred to as Care Coordinator. Care coordination is a system-wide approach to the deliberate organization of all Veteran care activities between two or more participants or systems to facilitate the appropriate delivery of health care services. Duties will include: Ongoing POC and clinical resource that promotes treatment engagement, especially during care transitions along the MH continuum of care Provides and/or ensures the Veteran (and family/caregiver/support person) has access to education, information, and resources for proactive self-management Complete MH Care Coordination needs assessment Develops initial MH Care Coordination interventions plan, including intended frequency of contact, as part of the overall care plan Documents needs assessments and interventions plan in the electronic health record (EHR) Monitors MH Care Coordination and treatment needs and adjusts the MH Care Coordination interventions plan, in collaboration with BHIP providers, as needed over time Supports evaluation of MH Care Coordination efforts to promote access, quality, Veteran and provider experience, and cost savings Communicates with the Patient Centered Management Module (PCMM) coordinator to ensure all MHTC assignments are current and visible in the EHR Participates in frequent team huddles (e.g., daily) and team meetings (e.g., weekly) Helps to organize flow of team huddle. Outreaches or facilitates outreach to Veteran to promote care continuity when other team members are unavailable (e.g., triage Veteran needs) Provides information/education to other healthcare and service providers to facilitate recognizing and respecting the Veteran's needs, strengths, and goals Coordinates care within and beyond the BHIP team by including BHIP team members, other VHA healthcare providers, and community providers to ensure that key components of mental health care delivery occur consistent with policy Responds to critical events (e.g., ED/UCC visits, inpatient stays, suicide behaviors, accidents, etc.) as they are known by gathering information, updating the team, coordinating any additional care or changes to care, and following up with the Veteran as needed Advocates for Veteran to receive necessary and culturally relevant care/services (e.g., care delivered with military cultural competence) Advocates for Veterans by working for systems improvement and eliminating healthcare disparities to promote Veteran well-being Is available to the Veteran to answer questions about needs, upcoming visits, care plans, and other questions not already handled by BHIP treating provider(s) Flexibly provides same-day access and walk-in services (i.e., triage) and either address immediate needs that do not require a treating team provider or facilitate a hand off to a treating team provider Aids in crisis intervention, as needed (e.g., manages medical and mental health emergencies appropriately, including suicidal and homicidal ideation) Collaborates with Suicide Prevention Coordinator and others to identify Veterans at high risk for suicide and others with complex needs to increase monitoring and enhance care with targeted suicide prevention strategies Facilitates urgent appointments and warm handoffs, as needed, with BHIP team members Ensures Veteran receive needed care through ensuring consult initiation and follow-up. Ensures consults are entered or referrals are made to providers, services, and resources appropriate to the Veteran's needs. Monitors whether referrals made by the BHIP team to other resources are completed and whether the Veteran is engaged in the planned level of care. Attempts outreach to the Veteran to try to increase treatment engagement Provides supportive outreach (e.g., via outreach calls or online outreach) to facilitate engagement until the Veteran can be seen by the appropriate mental health provider - especially during care transitions Facilitates Patient Aligned Care Team (PACT) assignments for Veterans not yet assigned to a Primary Care team Educates the Veteran on the team model and the Veteran's active role on the BHIP team Collaborates with UCC, inpatient, and residential services to coordinate the Veteran's admission, when needed, and discharge planning

Responsibilities

Ongoing POC and clinical resource that promotes treatment engagement, especially during care transitions along the MH continuum of care
Provides and/or ensures the Veteran (and family/caregiver/support person) has access to education, information, and resources for proactive self-management
Complete MH Care Coordination needs assessment
Develops initial MH Care Coordination interventions plan, including intended frequency of contact, as part of the overall care plan
Documents needs assessments and interventions plan in the electronic health record (EHR)
Monitors MH Care Coordination and treatment needs and adjusts the MH Care Coordination interventions plan, in collaboration with BHIP providers, as needed over time
Supports evaluation of MH Care Coordination efforts to promote access, quality, Veteran and provider experience, and cost savings
Communicates with the Patient Centered Management Module (PCMM) coordinator to ensure all MHTC assignments are current and visible in the EHR
Participates in frequent team huddles (e.g., daily) and team meetings (e.g., weekly)
Helps to organize flow of team huddle.
Outreaches or facilitates outreach to Veteran to promote care continuity when other team members are unavailable (e.g., triage Veteran needs)
Provides information/education to other healthcare and service providers to facilitate recognizing and respecting the Veteran's needs, strengths, and goals
Coordinates care within and beyond the BHIP team by including BHIP team members, other VHA healthcare providers, and community providers to ensure that key components of mental health care delivery occur consistent with policy
Responds to critical events (e.g., ED/UCC visits, inpatient stays, suicide behaviors, accidents, etc.) as they are known by gathering information, updating the team, coordinating any additional care or changes to care, and following up with the Veteran as needed
Advocates for Veteran to receive necessary and culturally relevant care/services (e.g., care delivered with military cultural competence)
Advocates for Veterans by working for systems improvement and eliminating healthcare disparities to promote Veteran well-being
Is available to the Veteran to answer questions about needs, upcoming visits, care plans, and other questions not already handled by BHIP treating provider(s)
Flexibly provides same-day access and walk-in services (i.e., triage) and either address immediate needs that do not require a treating team provider or facilitate a hand off to a treating team provider
Aids in crisis intervention, as needed (e.g., manages medical and mental health emergencies appropriately, including suicidal and homicidal ideation)
Collaborates with Suicide Prevention Coordinator and others to identify Veterans at high risk for suicide and others with complex needs to increase monitoring and enhance care with targeted suicide prevention strategies
Facilitates urgent appointments and warm handoffs, as needed, with BHIP team members
Ensures Veteran receive needed care through ensuring consult initiation and follow-up. Ensures consults are entered or referrals are made to providers, services, and resources appropriate to the Veteran's needs. Monitors whether referrals made by the BHIP team to other resources are completed and whether the Veteran is engaged in the planned level of care. Attempts outreach to the Veteran to try to increase treatment engagement
Provides supportive outreach (e.g., via outreach calls or online outreach) to facilitate engagement until the Veteran can be seen by the appropriate mental health provider - especially during care transitions
Facilitates Patient Aligned Care Team (PACT) assignments for Veterans not yet assigned to a Primary Care team
Educates the Veteran on the team model and the Veteran's active role on the BHIP team
Collaborates with UCC, inpatient, and residential services to coordinate the Veteran's admission, when needed, and discharge planning