General Summary:

The Behavioral Health Home (BHH) RN Care Manager is responsible for promoting effective clinical education to clients and staff; for delivering timely healthcare treatment to achieve optimal health, successful recovery, and quality outcomes; and to identify and aid in addressing warning signs of adverse health outcomes.

This position will be a key member of the BHH care team (see below) to ensure safe and effective transfers in the movement of clients across the health care continuum.

She/he will serve as the bridge between care settings and the client/family in the role of client educator, advocate and empowerment facilitator; but also providing information and guidance to the client/family with a focus on physical medical needs but also on mental health and substance use challenges.

It is expected that she/he will collaborate with external providers and ensure that clients are well connected to primary and specialty care to address their healthcare needs.

She/he will be part of the BHH care team consisting of a medical director, case manager, peer support, behavioral health counselor and psychiatric nurse practitioner.

The position will be part-time (8 hours) to start with expectation to increase to 12 hours as more clients participate in the BHH.

Aspects of the role may be carried out in a central office, client location, and/or remotely from home or other setting.

Essential Duties & Responsibilities:

• Collaborates with the BHH team to identify appropriate clients for care management, care coordination, and health education needs. Utilizes established BHH client criteria to facilitate successful engagement. Prioritizes referrals and activities according to intensity, need, and required follow-up.
• Provides extensive, individualized education to clients and families regarding their physical health, mental health, substance use conditions and optimal management of same.
• Assists in care coordination for clients identified as needing either PCP or BHH services. Evaluates aspects of each patient’s condition, diagnoses, medications, and support systems to formulate an individualized plan which will lead to successful outcomes.
• Medication self-management.
• Aids in completing chart reviews to ensure thorough client care.
• Use of a dynamic patient-centered record.
• Appropriate primary care and specialist follow-up.
• Knowledge of red flags.
• Formulates and implements a care management plan that addresses the client’s identified needs by assessing the client/family needs, issues, resources, and care goals; determining the choices available to individual clients with subsequent education on choices made. This care management plan will be mutually agreed upon by the BHH care team and the client/family. The RN CM contributes to evaluation and the effectiveness of the plan in meeting established care goals; revises the plan as needed to reflect changing needs, issues, and goals.
• Identifies and effectively utilizes community resources to meet the needs of clients/families; collaborates with residential staff and community partners to coordinate optimal service delivery.
• Facilitates shared decision making, promoting an engaged and activated client.
• Through motivational interviewing strategies, promotes self-management while empowering clients/families to achieve maximum levels of wellness and independence. Serves as a guide to the client and family, coaching in addressing critical issues and self-management tasks.
• Assists the client to identify and/or develop their support system and encourages the client to utilize their support system.
• Serves as a liaison to providers, clients and families for coordination of services.
• Contributes to the BHH databases of the designated population. Maintains accurate and timely documentation.
• Participates in regular BHH team meetings.

Values:

• Client and people centered: celebrates diversity in the workplace and welcomes all clients, families, and employees.
• Accountable: maintains an atmosphere of trust by working as a team member, showing respect for others, and the people we care for, and uses open and honest communication.
• Leader: promotes the services offered through various components of Day One and collaborates with relevant providers to advocate for our clients and families.
• Quality: meets professional development needs by attending trainings and participating in all scheduled group and individual supervisions.

Confidentiality:

On an ongoing basis strictly adheres to all Day One, Federal and State policies and procedures regarding the confidentiality of client, employee and agency information.

Supervisory Responsibilities:

None currently.

Physical Environment:

Most duties will be performed at the residential locations, outpatient office, or via virtual encounters. Some travel required to other Day One locations and/or outside events may be necessary.

Physical Effort:

Physical effort commensurate with routine office work. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.