Transition of Care Program Coordinator

Weekdays, 1st Shift!

General Description

Support the TOC Manager with engaging Enrollees to complete BH CP Participation Forms, Consent Forms and comprehensive assessments. Support the TOC Manager to ensure warm hand-offs to BH CP staff for the purpose of delivering ongoing care management services and may maintain a caseload of Enrollees following discharge from inpatient facilities where Brien Center Enrollees utilize services. The TOC Program Coordinator may assist the TOC Manager with developing, and possibly implementing, Person-Centered Treatment Plans (PCTPs) in collaboration with the BH CP Teams.

The TOC Program Coordinator will assist the TOC Manager in conducting initial outreach and engagement of Enrollees who utilize facility-based services and will support planning and implementation of interventions related to TOCs. This position supports the TOC Manager as well as Care Coordinators working with medically and psychologically or duel diagnosed complex individuals and their families.

Essential Functions

• Support the engagement of Brien Center BH CP Assigned and Engaged Enrollees in the inpatient, ED and crisis settings to deliver BH CP services.
• Collaborate with the TOC Manager to review and prioritize a list of hospitalized BH CP Assigned and Engaged Enrollees on a daily basis; meet with Enrollees immediately upon identification of all individuals who are utilizing facility-based services as assigned by the TOC Manager.
• Participate in the delegation of support functions to additional BH CP staff (e.g. Care Coordinators), to meet with 100% of Enrollees who utilize facility-based services on a daily basis. Follow-up with Enrollees who are not available at an initial contact on the same day of such contact. Track and follow-up with Enrollees who have left the facility on the day of discharge either directly, or in combination with BH CP team members.
• Complete all required documentation in a timely manner as assigned by the TOC Manager.
• Consult with Brien Center BH CP medical, behavioral and other staff, as needed, to meet the person-centered needs of Brien Center BH CP Enrollees as assigned by the TOC Manager.
• Participate in Interdisciplinary Care Team (ICT) meetings, as directed by the TOC Manager , for the purpose of planning TOCs. Collaborate with BH CP staff to plan and execute such meetings and transitions.
• Collaborate with Berkshire Health System care management and discharge planning staff, providers, community-based Social Service Providers, BH CP team members, Crisis Teams, and other community-based supports to ensure the delivery of whole-person BH CP care management services including, but not limited to, effective transitions of care for Enrollees who utilize inpatient, ED, crisis and other facility-based health care services under the direction and supervision of the TOC Manager.
• Attend and actively participate in TOC and discharge planning meetings and the development of interventions at the earliest point in the Enrollee’s facility -based care as requested by the TOC Manager.
• Participate in establishing positive relationships with community organizations and services for the purpose of initiating and implementing meaningful TOCs under the direction of the TOC Manager.
• Collaborate with Brien Center BH CP staff to review and augment Assessments and PCTPs to include appropriate information and goals for individuals who experience facility-based TOCs.
• Provide temporary assistance with transportation to needed TOC-related appointments in the absence of Care Coordinator or other options as directed by the TOC Manager.
• Assist in the management of Care Coordinator follow-up of all TOC interventions in collaboration with BH CP staff as directed by the TOC Manager.
• Support the TOC Manager in meeting reporting requirements to inform the ACO of TOC activities.

Qualifications

• Meet Community Health Worker Certification Requirements
• Minimum of two years experience successfully performing and engaging individuals with BH or other health care needs in the community or in an inpatient setting
• Experience in community-based behavioral health support programs and/or inpatient support programs
• Experience with accessing local resources, navigating health, behavioral health and/or substance use treatment systems and/or in working with inpatient hospital staff
• Valid driver’s license with reliable transportation and appropriately insured vehicle required.
• Experience evaluating Enrollees based on the Stages of Change Model of behavior change in a manner that is consistent with Certification Requirements
• Knowledge of Substance Use Disorder treatment paths including medication assisted treatment options, community resources, and knowledge of 12 Step recovery model
• Willingness to perceive substance use treatment and recovery through the lens of chronic disease management and holistic care

Skills

• Ability to apply Community Health Worker training Certification requirements
• Ability to successfully perform community-based outreach
• Ability to proactively work with a wide variety of people and personalities in a team-based environment
• Ability to represent the agency in a professional manner within a team-based environment
• Ability to maintain a high regard for confidentiality and the handling of confidential information
• Excellent customer service and communication skills
• Excellent motivation and desire to support the needs of individuals with Serious Mental Illness
• Strong motivational interviewing skills

4Other Requirements

• Driver’s license check (RMV).
• Criminal Offender Record Information Check (CORI).

Working Conditions

• Works in community settings in a collaborative manner

Physical Conditions

• Visual and hearing acuity; correctable.

• Reasonable accommodations may be made to enable qualified individuals with disabilities to perform the essential functions.