Senior Clinician - Pathways

JOB SCOPE:

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.

ESSENTIAL FUNCTIONS:

• 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 AH class members.
• Acts as a liaison and collaborates with Department of Health, Managed Care Plans, and Housing Contractors.
• Short term counseling (substance use, coping skills, trauma informed, decision making) and Risk Assessment/Safety Planning;
• Running groups and life skill training for patient population;
• Participate in both the development and implementation of a community care plan that includes formal and informal supports that increase opportunities for improved quality of life. Focus is on creating meaningful and productive daily activities in the community;
• Assessing Housing Supports and Housing Assistance and Placement for those who are homeless. Services may include 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;
• Work with recipients and their housing providers to resolve clinical issues that are impacting on 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.
• Foster relationship with community provides to ensure that recipients are connected with appropriate services as they transition back into the community and to share or collect collateral information;
• Patient navigation by accompanying to first behavioral health and medical appointment, travel training, reengagement in community care, referral to services with ability to identify and address potential services and barriers to obtain and maintain such services
• Review documentation and conduct comprehensive psychosocial assessments to determine the medical, psychiatric, housing and other social needs in the community. Obtain historical and collateral information from multiple sources as it relates to mental and physical health, substance use, and criminal history;
• Develop a short-term person centered treatment plan to assist the recipients’ towards achieving their goals and modify treatment plans according to changes in recipients’ status.
• Monitor, evaluate and record recipient progress with respect to treatment goals;
• Establish collaborative working relationships with inpatient treatment teams, community providers, and other partners and plan with them for appropriate discharges for recipients;
• Counsel recipients in individual and group sessions to assist them in dealing with substance abuse, mental and physical illness, family issues, housing problems and unemployment;
• Provide ongoing family conferences and psychoeducation to families and others within the support network;
• Provide out of hours crisis intervention services to recipients and their support network, including respite referrals and other diversion and stabilization services;
• Attend and participate in team meetings and supervisory sessions;
• Perform other related duties as assigned;

EDUCATION AND EXPERIENCE:

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.