Provides professional comprehensive care aligned with ICARE values to patients of the Strong Memorial Hospital/ Strong Ties Assertive Community Treatment (ACT) team. Collaborates with health, behavioral health and social service providers and is responsible for assessing patient’s needs, developing and managing care plans with patients enrolled in ACT services. Special focus will be serving the most complex, high utilizing patients that need comprehensive community treatment and care management services. Services include, but are not limited to: care coordination, health promotion, patient and family support, referral to community and social supports, crisis intervention, and family support.
Under general direction and with considerable independence, works with Strong Ties ACT team patients. Visits patients in their community setting to assess their progress toward meeting the goals of the care plan and to monitor compliance with the treatmentplan.
Teaches, guides, and assists patients and family members to insure their clear understanding of the patient's needs and expectations of the specific care plan. Makes recommendations to mental health professionals regarding treatment plans.
Participates on a rotational basis in on-call group as back-up to Life Line during evening/weekend hours. Responds, as necessary, after hours to psychiatric crises in the community.
Conducts assessments for enrollees identifying service needs that contribute to developing a patient centered care plan. Carries out strategies for implementation of treatment plan by: establishing contact with various service providers and family members; assuring appropriate utilization of life support services in the community; and takes initiative for suggesting appropriate community services that would enable the patient to function at his/her optimal
level in the community.
Maintains contact with psychiatric service providers to assess: appropriateness of placement; continued progress of patients; and other supplemental needs of patients. Implements the proper intervention strategies with minimal supervision from the mental healthprofessional.
Reviews and discusses plan with patient and care team, focusing on linking the individual to needed clinical and social services with system and community providers.
Documents patient contacts and patient progress in the medical record and assists patients with paperwork, updating treatment plans, completing psychosocial updates, correspondence, etc. necessary to ensure linkage to appropriate resources.
Documents patient outreach and services in electronic medical record system and ensures that all documentation is timely, accurate and in compliance with Hospital policies and Health Home regulations. Conducts quality reviews of
Establishes and maintains cooperative working relationships with community providers to obtain needed services and support for enrolled patients.
Utilizes community and family resources to create sustainable support systems for patients. Develops, reviews and discusses plan with patient and care team, focusing on linking individuals to clinical and social services with system and
Monitors utilization of services, and works to reduce unnecessary emergency room utilization and inpatient admissions by encouraging enrollees to follow treatment recommendations and keep appointments, supporting patients in transitions of care, supports population health initiatives, ensures that care is accessible, attended and effective, and works with the patient to reduce barriers
Coordinates patient outreach (in person, primary care settings, behavioral health clinics, community settings including patient homes, jail, hospitals, shelters, etc.), management activities and interactions focused on locating, connecting and retaining patients in ACTtreatment.
Bachelors Degree in an appropriate human services field and; or an equivalent combination of education and experience required.
2-3 years of experience providing direct services to individuals diagnosed with serious mental illness, intellectual/developmental disabilities, alcoholism/substance abuse required; or experience
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How To Apply
All applicants must apply online.
EOE Minorities/Females/Protected Veterans/Disabled
Location: Strong Memorial Hospital
Full/Part Time: Full-Time
Opening: Full Time 40 hours Grade 053 Psychiatry SMH Strong Ties
Schedule: 8 AM-5 PM