Care Coordinator

About the role

The Support and Engagement Specialist (CC) will work with clinic patients to coordinate the full range of physical health, behavioral health, and community-based services. The CC is accountable for assessing clients' needs, coordinating with indicated entities in order to facilitate authorization as required, and ensuring access to identified needed physical health care, behavioral health care, and community-based supportive services, as necessary to support the achievement of individualized health goals.

Responsibilities

• Use evidence-based outreach strategies to continually engage with clients and link them to healthcare.
• Initiate patient tracking via internal database and resident roster.
• Proactively reach out to patients requiring follow up by working with housing-based case manager, medical providers, and mental health providers.
• Engage and support patient family and significant others as clinically appropriate.
• Use effective communication skills such as active and reflective listening to build rapport with vulnerable and difficult-to-engage clients, including clients who have experienced chronic homelessness.
• Participate in partnerships and coalitions with other community providers to increase the portfolio of partnerships accessible to the CC Department.
• Provide immediate assistance to patients as needed, including locating emergency shelter, food resources, etc., based on internal on-call Care Coordination schedule.
• Interview and assess clients to identify biological, psychological, social, and economic factors which may interfere with attaining stability and optimum health.
• Apply critical thinking skills and sound decision-making capabilities, often under pressure, in complex situations as needed.
• Evaluate each client's past, present, and future medical, psychological, social, and economic functioning as indicated.
• Evaluate each client's stage of change and readiness for self-management.
• Implement effective strategies for engagement and rapport building.
• Demonstrate expertise in condition(s), and evidence-based strategies to address condition(s), common in the patient population, including: Domestic Violence, Substance Use, Mental and/or Physical Health Condition(s), Re-Entry, Chronic Homelessness, etc.
• Administer structured assessments, including assessments on Social Determinants of Health, to gather, track, and assess client progress.
• Understand the Coordinated Entry System protocols and administer the VI-SPDAT tool for individuals.
• Coordinate and facilitate effective communication among providers.
• Engage and initiate case conferencing with multidisciplinary team as needed.
• Utilize appropriate motivational interviewing interventions to effectively address each client's current stage of change.
• Apply clinical and behavioral interventions, such as motivational interviewing, that decrease and, if possible, prevent complications as well as optimize disease control and patient well-being.
• Provide accompaniment services to clients as needed, determined by patient assessment and interviews.
• Create SMART goals in collaboration with patients.
• Promote self-management skills for each client to demonstrate an ability to effectively engage with health and service providers as well as to achieve self-directed, individualized health goals that promote recovery, improved functional and/or health status, and/or prevent or slow declines in functioning.
• Engage in additional care coordination activities as indicated, which may include:
• Maintain housing.
• Complete substance abuse referrals for the indicated level of care, such as inpatient detox, outpatient individual/group treatment, and residential treatment, per existing protocol.
• Complete mental health referrals for the indicated level of care/service, such as FCCS and FSP as needed.
• Collaborate with on-site mental health practitioners to ensure adequate level of services.
• Conduct suicidality assessments and engage subsequent workflow to provide emergency assistance to patients based on mental health status and risk.
• Link clients to appropriate services, including:
• Maintenance of housing.
• Substance abuse treatment.
• Mental health care.
• Obtain basic needs.
• Public benefits.
• Provide client assistance with requesting copies of birth certificates, identification, public benefits information, and other documentation as needed.
• Ensure appropriate care at level of care transitions by providing evidence-based transition planning, which may include:
• Scheduling follow-up appointments with recommended outpatient providers and/or community partners.
• Supporting clients and each client’s support system during discharge from hospital and institutional settings.
• Ensure continuity of care by:
• Ensuring that all identified biopsychosocial areas, including environmental factors, are addressed with care coordination and medical treatment planning.
• Ensuring that each client’s care is continuous and integrated among all service providers.
• Coordinating activities and communication among each client’s multi-disciplinary treatment team.
• Promote timely processing of each client’s subspecialty referrals.
• Communicate with internal departments and/or outside care agencies as well as IPA/health plans, as applicable, to initiate referrals and to ensure appointment obtainment.
• Record requests for these referrals/appointments.
• Coordinate with authorizing and prescribing entities as necessary to reinforce and support each client’s health goals.
• Accompany identified clients to critical appointments as appropriate.
• Enter all appropriate data into the Homeless Management Information System (HMIS), following the criteria set out by HUD for data elements and the workflows set by the Los Angeles Homeless Services Authority (LAHSA).
• Utilize and improve internal tracking systems to accurately capture Care Coordination progress within assigned roster.
• Document all evaluations, care plans, interventions, and referrals performed per established EHR processes.
• Synthesize complex information obtained from assessments, trainings, and research to implement up-to-date, evidence-based interventions for impactful Care Coordination.
• Participate and obtain certification in LA Care’s training academy for Care Coordination practices.
• Participate and obtain certification in ongoing training topics as assigned, including, but not limited to: Motivational Interviewing, De-Escalation Strategies, Fair Housing, Trauma-Informed Care, Safety Planning, Accompaniment, Case Management Core Functions.
• Other duties as assigned.

Qualifications

• Bachelor’s degree in social work or related field from a four-year college or university is preferred.
• Two years of case management experience is preferred.
• Prior experience working with individuals experiencing homelessness, substance use, physical health conditions, mental health conditions.
• Experience with Electronic Health Records, Microsoft Word, Microsoft Access, and Microsoft Excel is preferred.
• Experience with HMIS and CHAMP databases preferred.
• CPR Certification required.
• Bilingual Spanish a plus.