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.
Children’s Care Coordination provides services to children ages 5 to 18 enrolled in the various Health Homes Program. The primary goal and service philosophy of the program is to provide recovery-oriented care coordination which is widely available, accessible, flexible, personally tailored and responsive to the individual child and family needs. 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 incarcerations.

QUALIFICATIONS:

• Bachelor’s degree in social work, psychology or a related health/human services field with two (2) years of direct work with the target population. OR Professional Degree/certification in healthcare field.
• Skills in the areas of crisis intervention, time management, psychosocial rehabilitation skills Ability in linking clients to a broad range of services essential to successfully living in a community setting (e.g., medical, psychiatric, social, educational, legal, housing and financial services
• Fluency in second language preferred

• Accountable for engaging and retaining Queens 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.
• Tracks and shares health home members’ information and care needs across providers by utilizing electronic databases and monitors outcomes and initiate changes in care, as necessary, to address health home members’ needs.
• 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).
• Completes contact notes, incident reports, and other required documentation and maintains accurate recordings in electronic case files in a requested timely fashion.
• Completes CANS-NY training and examination to properly assess clients being served
• Checks that health home members receive test results and tracks that patients follow up with medical directions. Prepares and follows-up on a list of health home members who need preventive or metabolic screening, appointment reminders.
• 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).
• Monthly Face to face visit with client/child as well as monthly follow up (telephonic or face to face) with various providers/collaterals (i.e. guidance counselors, parents/guardians, therapists, ACS etc.)
• Aids the health home members in identifying the primary care physician and multidisciplinary teams of medical, mental health, chemical dependency treatment providers, social workers, nurse’s nutritionists/dieticians, pharmacists, outreach workers including peer specialists and other care providers to assure that enrollees receive needed medical, behavioral, and social services in accordance with a plan of care.
• Responsible for maintaining the security of all data files and employ approved methods of data encryption to prevent theft of personally identifiable information.
• Refer Queens health home members to peer supports and coordinate peer supports, support groups, and self-care programs to increase client’s and caregivers knowledge about the individual’s diseases, promote the health home members’ engagement and self-management capabilities, and help the to improve adherence to their prescribed treatment order to allow them to make informed decisions.
• Assure timely and comprehensive transitional care from an inpatient facility (hospital, rehabilitative, psychiatric, skilled nursing or treatment facility) to follow-up with post discharge interventions in order to prevent health home member’s avoidable readmission after discharge and to ensure proper and timely follow up care.
• Develops and maintains health home networks with primary medical and specialty practitioners and mental health providers, substance abuse service providers, community based organizations, managed care plans, emergency rooms, hospitals, and residential/rehabilitation settings, community-based services to ensure coordinated, and safe transition in care for its patients who require transfer to/from sites of care.
• Utilizes regional health information organizations (RHIOs) and other data systems to track and share health home members’ information and care needs across providers, monitor their outcomes, and initiate changes in care as necessary to provide the health home prompt notification of an individual’s admission and/or discharge to/from an emergency room, inpatient, or residential/rehabilitation setting and address immediate needs in order to maximize optimum care and timely treatments, services and referrals.
• Utilizes and electronically tracks all specialty medical, behavioral, and support service referrals made for health home members, and ensures that the member follows up and receives all of the care they need. Tracks and arranges appointments, educate health home members and coordinate all aspects of the member’s health and community services.
• Responsible for direct service provision of services to the consumer based on needs as established and documented in comprehensive assessments and service plans. This will be re-evaluated and adjusted in the care coordination platform every 6 months or as needed (per goal change or change in life event)
• Work schedule includes holiday coverage to accommodate the coverage needs of the program when required. 24 hours/seven days a week availability to provide information and emergency consultation services and provide escorts to health home members from ER, hospital and other settings to alternative level of care.
• Reports to Behavioral Health Services Administration and/or Agency Administration issues that may have a negative impact on the reputation of the Agency, client and/or staff welfare or any corporate compliance issue.
• Cooperates with any and all investigations conducted by the Agency, funding sources and any other authorized agencies/entities.
• Performs other related duties as requested or assigned by agency management.
• As this is an evolving program, additional responsibilities may be added and/or revised. Participates in committees as directed