For over 125 years, Catholic Charities Brooklyn and Queens has been providing quality social services to the neighborhoods of Brooklyn and Queens, and currently offers 160-plus programs and services for children, youth, adults, seniors, and those struggling with mental illness.
The Care Coordination program offers services to adults and children ages 6 to 18 enrolled in the Coordinated Behavioral Care (CBC) Health Home Program with a history of serious mental illness and/or multiple hospitalizations. The goal is to connect clients and families to various community resources identified as beneficial to the clients’ overall holistic well-being in order to reduce emergency room visits, inpatient stays and criminal justice involvement.
STATEMENT OF THE JOB
Under the direct supervision of the Team Supervisor, the Care Coordinator has overall day-to-day responsibility and accountability for coordinating all aspects of an assigned health home member’s care with complex medical and/or psychiatric co-morbid conditions and for facilitating their access to the full range of medical and psychosocial services in an efficient and effective manner.
Duties of Care Coordinator focus on integration and coordination of physical health and mental needs. The Care Coordinator has to become an active participant in all phases of care transition to assure that enrollees received all required mental and medical follow up care and services and re-engagement of patients who have become lost to care.
The Care Coordinator electronically monitors and tracks data regarding health home member and alerts all members of the Care Team when follow-up is required.
DUTIES AND RESPONSIBILITIES
Demonstrates commitment to the vision of Health Home and strategic priorities to ensure their achievement.
Accountable for engaging and retaining health home members in care, coordinating and arranging for the continuous provision of services, supporting adherence to treatment recommendations, monitoring and evaluating their needs, including prevention, wellness, medical, specialist and behavioral health treatment, care transitions, and social and community services where appropriate through the creation of an individual plan of care.
In collaboration with the health home members, their family and/or caregivers, and other service providers develops, manages and coordinates a comprehensive individualized person-centered care plan that coordinates and integrates the continuum of medical, behavioral health services, rehabilitative, long term care and social service needs and clearly identifies the primary care physician/nurse practitioner, specialists, behavioral health care providers, care manager and other providers directly involved in the individual’s care.
Ensures the availability of priority appointments for health home members to care services including physical, psychiatric, and substance abuse within their health home provider network to avoid unnecessary, inappropriate utilization of emergency room and inpatient hospital services.
Promotes evidence based wellness and prevention by linking health home members with resources for smoking cessation, diabetes, asthma, hypertension, self-help recovery resources, and other medical services based on individual physical needs and preferences.
Reassesses needs for Health Home services and reviews health home members’ historical or targeted clinical measurements (i.e. number of ER visits and inpatient psychiatric admissions).
Identifies potential barriers to successful care and resolutions to those barriers.
Completes contact notes, incident reports, and other required documentation and maintains accurate recordings in electronic case files in a requested timely fashion.
Outreach via phone to health home members between visits (check on self-care, medication fills, treatment plan, schedules visits, tests/follow-up) Monitors that the health home member completes post-visit follow-up (fill prescriptions, make appointments).
Aids…