Primary Purpose Establishes and maintains an efficient, patient-centered behavioral health process by which persons seeking care at the ACCESS Clinic, may access integrated behavioral health services as recommended by the Ryan White Grant Program to ensure patient access to comprehensive HIV primary care. PHSD behavioral health staff are responsible for developing, implementing and monitoring individual behavioral health plans of care and communicating these plans to patients and other stakeholders in compliance with program/PHHS policies and procedures.
MINIMUM SPECIFICATIONS Education - Must have a Master's degree in Social Work, Counseling, - OR - must be a graduate of an accredited school of Nursing. Experience - Must have four (4) years of hospital or community based patient care preferably in assigned clinical area. - Prefer one (1) year case management experience with persons living with HIV and/or persons with mental illness, homelessness, or chemical dependency. - Prefer case management, utilization review, and/or discharge planning experience. - Prefer three (3) years of experience working in an urban healthcare system.
Certification/Registration/Licensure - Must have current healthcare provider CPR course completion card from one of the following: - American Heart Association - American Red Cross - Military Training Network - Case Manager only: - Must be licensed as a Social Worker by the Texas State Board of Social Worker Examiners. - Counselor only: - Must be licensed as a Licensed Clinical Social Worker (LCSW) Social Worker by the Texas State Board of Social Worker Examiners or be a Licensed Professional Counselor (LPC). - Nursing only: - Must have current, valid RN license or temporary RN license from the Texas Board of Nursing; or, valid Compact RN license.
Skills or Special Abilities - Must demonstrate a knowledge of community resources of benefit to clients with alcohol/substance abuse dependencies and /or mental health illness. - Must be able to communicate and collaborate effectively with a diverse group of patients, families and healthcare staff. - Must be able to demonstrate a working knowledge of specific patient populations, and be able to demonstrate knowledge of disease processes affecting this group. - Addresses social determinants in patient care plans. - Must be able to demonstrate a working knowledge of PC operations and the ability to use word processing and spreadsheet software in a Windows environment. - Must be able to demonstrate a working knowledge of the laws and regulations governing Medicare, Medicaid and community-based funding sources. - Must be self-directed and capable of priority setting. - Uses a holistic approach and persists when solving problems. - Utilizes creativity and innovation in attaining desired outcomes. - Must be able to demonstrate patient centered/patient valued behaviors. - Works in a highly organized manner, capturing and attending to details as well as the bigger picture. - Acts with a sense of urgency. - Works effectively in an ambiguous environment.
Responsibilities Conducts assessment of patients to develop a case management plan of care. Gathers information from patient, physicians, other providers, staff and all caregivers. Determines funding sources for patients and potential eligibility if appropriate.
Plans and develops specific objectives, goals and actions designed to meet the patient's needs as identified through the assessment process. Identifies at-risk populations using approved screening tool and follows established reporting procedures. Provides screening and assessments for chemically dependent and/or patients with mental health issues, determining the level of intervention needed, discussing alternatives with patients and assisting them with implementation.
Provides on-going supportive individual and group interventions that support mental health and substance abuse. Collaborates with all members of the multidisciplinary team and the patient to implement the plan of care. Coordinates with healthcare team and ancillary healthcare providers to implement the plan of care.
Monitors the patient's progress, intervening as necessary and appropriate to ensure that the plan of care and services provided are patient focused, high quality, efficient, and cost effective. Communicates all financial counseling as appropriate. Addresses and resolves system barriers impeding diagnostic or treatment progress.
Proactively identifies and resolves delays and obstacles to discharge. Ensures/maintains plan consensus from patient/family, physician, and payor. Ensures scheduling of appointments and patient appointment follow-up; provides relevant clinical information to primary care, referring and specialty providers as needed.
Communicates plan of care to patient and their family providing updates and reassesses the plan of care to determine effectiveness. Completes appropriate case management documentation. Evaluates the plan of care at appropriate intervals to determine effectiveness in meeting outcomes and goals.
Works with nursing and other disciplines to ensure that discharge needs, including teaching, are met. Documents case management activity to include interventions and outcomes of case management involvement (clinical, financial and variance). Provides exceptional patient experience and makes human connections including being mindful of patients, creating an atmosphere of respect and courtesy, listening and responding to patient concerns, providing clear explanations of care delivery and care planning; all reinforced through standardized approaches.
Serves as patient advocate, focusing on patients' needs, rights, confidentiality and cultural preferences. Serves as a resource person for specific clinical and patient care issues, helping to negotiate desirable patient outcomes. Serves as a liaison between provider and patient/family to facilitate communication and services.
Collaborates with Care Management staff on Utilization Management activities for assigned patients as needed. Refers clinical specialty quality review activities as needed. Educates all providers on the key case management processes and outcomes.
Communicates with Care Management Support Team to facilitate covered day reimbursement certification for assigned patients and discuss payor criteria and issues on a case by case basis with clinical staff and follows up to resolve problems with payors as needed. Transitions patients through the health care system based upon individual and patient population needs. Directs liaison activities to appropriately integrate the patient into the health care continuum including procuring of services, health promotion and counseling, disease prevention, health education and screening, and community resource linkage.
Serves as an advocate for the patient and family throughout the entire episode of care. Maintains availability to the patient/family as a resource to facilitate communication among providers and to monitor services rendered. Remains involved until the planned level of functional health is achieved by the patient and/or discharge criteria are met.
Engages in special projects and serves on committees, as assigned. Job Accountabilities Identifies ways to improve work processes and improve customer satisfaction. Makes recommendations to supervisor, implements, and monitors results as appropriate in support of the overall goals of the department and Parkland.
Stays abreast of the latest developments, advancements, and trends in the field by attending seminars/workshops, reading professional journals, actively participating in professional organizations, and/or maintaining certification or licensure. Integrates knowledge gained into current work practices. Maintains knowledge of applicable rules, regulations, policies, laws and guidelines that impact the area.
Develops effective internal controls designed to promote adherence with applicable laws, accreditation agency requirements, and federal, state, and private health plans. Seeks advice and guidance as needed to ensure proper understanding.