Coordinate services for clients/patients who are shared throughout programs in order to ensure a holistic, whole-person approach is taken for all eligible participants in the Certified Community Behavioral Healthcare Clinic (CCBHC) demonstration project. CCBHC is defined as a no walls, person-centered system of care that facilitates access to and coordinates of the full array of, behavioral health care, long-term community-based services and supports and primary and acute physical health services.
ESSENTIAL DUTIES AND RESPONSIBILITIES include the following. Other duties may be assigned.
-Identify and engage CCBHC clients who are seen at Catholic Charities Diocese of Trenton (CCDOT) and provide navigation services through the continuum of care.
-Assist new CCBHC clients who are current CCDOT clients in completing paperwork and releases of information needed.
- Be the system navigator and point of contact for shared CCBHC/CCDOT clients and families, with clients and families having direct access for asking questions and raising concerns
-Assist clients with understanding the relevant details of the visit, as requested by either the client or the treatment team
-Schedule appointments, as requested by the treatment team and explain purpose of appointments in clear and simple language
-Participate as a member of a multi-disciplinary team including both medical and psychiatric members towards the development of treatment plans and implementation of services.
-Coordinate within multi team and community services as needed to ensure that preventative and health promotion needs are addressed as part of the holistic, whole-person, culturally-sensitive integrated care
TEACHING & CLIENT EDUCATION
-Provide as-needed education to clients during medical appointments in order to assist in the understanding of disease knowledge, medication compliance, specialty services recommended by primary care provider and/or any other medical needs the patient may require assistance in understanding
-Assist clients and their families in problem solving potential issues related to the health care system, financial or social barriers (e.g., request interpreters as appropriate, transportation services or prescription assistance).
-Negotiate on behalf of the client, as needed, with the treatment team, and patients themselves by creating reasonable goals, clarifying the issues to be negotiated, following through with the agreement reached, while remaining flexible and consider culturally-sensitive and holistic alternatives.
-Maintain caseload and complete notes for all care coordination services
-Ensure that billing units are entered and subunits accurately reflect services provided
-Monitor data aggregation to ensure all measures data is being recorded
-Monitor number of units and frequency of services based on level of need
-Provide weekly data to managers and follow-up with programs on no-shows, client engagement issues and increased use of or need for services
-Complete required interagency and other necessary paperwork.
-Monitor confidentiality in accordance with CCDOT policy and legal requirements.
-Follow required office procedures in a cooperative manner.