Senior Clinician - Pathways

About the Role

Licensed Mental Health Professional to work on a new NY State Office of Mental Health (OMH) funded innovative Adult Home based care transition team that exclusively serves individuals transitioning from an Adult Home into the community. The role will involve addressing the preparatory needs of participants in the early stages of discharge planning, development of daily living skills, and coping mechanisms through group and individual work at the Adult Home. The team will follow individuals into the community using the Pathway Home model of care to ensure that they become both linked and engaged with identified community providers and that their support network is sufficient to meet their needs. The role will require some on-call coverage.

Responsibilities

• Engagement beginning at the Adult Home, involvement in transition planning, and a needs assessment of community transition supports essential to stabilizing the individual.
• Monitors appropriate discharge and ongoing care planning at pre- and post-transition for Adult Home class members.
• Acts as a liaison and collaborates with Department of Health, Managed Care Plans, and Housing Contractors.
• Provides short-term counseling (substance use, coping skills, trauma-informed, decision-making) and Risk Assessment/Safety Planning.
• Runs groups and life skill training for the patient population.
• Participates in both the development and implementation of a community care plan that includes formal and informal supports to increase opportunities for improved quality of life, focusing on creating meaningful and productive daily activities in the community.
• Assesses Housing Supports and Housing Assistance and Placement for those who are homeless, including completing HRA 2010e, applying for housing, prepping for interviews, follow-up with housing providers, and assistance with moving in (day of move) with obtaining housing supplies and learning the neighborhood.
• Works with recipients and their housing providers to resolve clinical issues impacting the recipient’s ability to obtain, manage, and retain supportive housing.
• Troubleshoots clinical issues and escalated Adult Home concerns between the CBC Health Home and the DOH and other stakeholders.
• Fosters relationships with community providers to ensure recipients are connected with appropriate services as they transition back into the community and to share or collect collateral information.
• Provides patient navigation by accompanying recipients to their first behavioral health and medical appointments, travel training, reengagement in community care, and referral to services, while identifying and addressing potential barriers to obtaining and maintaining such services.
• Reviews documentation and conducts comprehensive psychosocial assessments to determine medical, psychiatric, housing, and other social needs in the community. Obtains historical and collateral information from multiple sources related to mental and physical health, substance use, and criminal history.
• Develops a short-term person-centered treatment plan to assist recipients in achieving their goals and modifies treatment plans according to changes in recipients’ status.
• Monitors, evaluates, and records recipient progress with respect to treatment goals.
• Establishes collaborative working relationships with inpatient treatment teams, community providers, and other partners to plan for appropriate discharges for recipients.
• Counsels recipients in individual and group sessions to assist them in dealing with substance abuse, mental and physical illness, family issues, housing problems, and unemployment.
• Provides ongoing family conferences and psychoeducation to families and others within the support network.
• Provides out-of-hours crisis intervention services to recipients and their support network, including respite referrals and other diversion and stabilization services.
• Attends and participates in team meetings and supervisory sessions.
• Performs other related duties as assigned.

Requirements

• Master’s degree or higher in social work, mental health counseling, nursing, or psychology.
• A minimum of 2 years post-masters work experience in the mental health and criminal justice field, preferably with the target population.