Transition Care Coordinator

FLACRA•Village of Clifton Springs, NY

13d•$19 - $20

About The Position

The goal of the Certified Community Behavioral Health Center (CCBHC) is to improve patient health outcomes and supporting clients in the behavioral, mental health and social determinant needs by supporting the navigation to and coordination of clinical and non-clinical services. The CCBHC will deploy a high-quality, consistent set of protocols including screening, intake, outreach, navigation and coordination services that help connect clients in need to critical services. Duties: Services will be driven by the individualized goals of the client and the primary role of the associated projects is to support coordination of care with clients and service providers. The methods used to accomplish this goal may include: Engage with client currently in agency Residential programs and educate clients of services available through enrollment in CCBHC programs through group and individual sessions. Assist Residential teams in discharge planning and referrals to mental health, substance use and primary care appointments, through collaboration for clients soon to be engaging in Community based programs. Developing strategies with the client to improve attendance at mental health, substance use and primary care appointments, including attending initial appointments with the client Developing and completing a thorough review of the service client’s existing treatment and crisis plans Modeling strategies and behaviors that will promote successful engagement in the health care delivery system Supporting coordination of care and referrals for clients with complex and/or emergent needs for support. Promoting enrollment into Health Home Care Management and/or Home and Community Based Services (HCBS) as eligible. The impact of such a role may include: Keeping people out of hospital and emergency rooms by supporting well-care connections and utilization of services before needs are emergent. Improving quality of life Promoting better health for the whole person Offers support in moving towards recovery goals through care coordination activities. Client Follow Up: Introduce and meet with client and CCBHC Care Coordinator for initial appointment and assist for smooth transition primary assistance from Transitions Coordinator to Care Coordinator for on-going support. Provide phone and face-to-face follow-up to clients and service providers. Support Practice Change and Education : Provide feedback (both written and verbal) regarding what has been learned from the outreach and engagement process as requested. Provide project updates during staff meetings within the context of Lessons Learned: What is Working.

Requirements

HS Diploma/GED required
Associate’s Degree Required in Health Care Related Field preferred
Minimum 1 year related experience, preferably in Behavioral Health
Ability to establish supportive client relationships
Ability to perform duties in a stable, consistent, and predictable manner
Valid NYS Driver’s License in good standing
Excellent written and verbal communication skills.
Demonstrated ability to communicate effectively and work cooperatively with culturally diverse persons, staff and multiple service provider agencies.
Knowledge of local behavioral health system and social determinant supports.
Ability to multi-task, have good problem solving and time management skills and the ability to remain calm in a crisis.
MS Excel experience and skill in data collection and entry.

Responsibilities

Follow up with patients for care coordination services
Deliver palliative care and related health care services to children and families
Oversee care coordination and health coaching for the patients
Manage assigned panel of chronic care patients
Ensure that patients are receiving appropriate care
Work with patients to plan and monitor care
Bringing the benefits of coordinated care to patients
Facilitate the daily operations of the department
Oversee care coordination for the primary care practice's patients
Meet member in various health care settings
Interact in multiple care settings
Communicate essential patient information to home care clinicians initiating patient care
Coordinate care plans, discharge planning, and long term care services
Receiving quality care from caregivers
Contacting patients to schedule transitional care services and home visits
Identify progress toward desired care outcomes; intervening to overcome deviations in the expected plan of care; reviewing the care plan with patients in conjunction with the direct care
Identify the primary care team involved in the specialty patient care
Utilize assessment skills and risk assessment tools to identify patients with actual or potential care needs that would require care coordination
Promote adherence to a care plan
Connect patient back to primary care physician and primary care coordinator team