New Horizons of the Treasure Coast, Inc.
  • Mobile Crisis Response Team
  • Fort Pierce, FL, USA
  • Full Time

GENERAL SUMMARY

Provides care coordination to assigned individuals involved with MCRT crisis intervention. Responsible for assisting agency/organizational staff and/or clients by providing referrals to both internal and external systems and organizations to help support, or by monitoring referrals and linkages.  Care Coordinator will be responsible for monitoring care linkages and/or following-up with clients (if services are refused) for 72 hours to ensure successful care linkages.  Ongoing care coordination provided by the coordinator will help to ensure that individuals receive timely and appropriate services and to monitor the success of referrals.  The Care Coordinator will also assess (on an ongoing basis) level of suicide/homicide risk, stressors/needs, and adequacy of safety measures/supports.  The provision of care coordination services will allow for adjustment of referrals or modification of services as necessary, and strengthens continuity of care for the individuals served and their family.

MINIMUM QUALIFICATIONS

Bachelor's degree from an accredited university or college with a major in counseling, social work, psychology, or a related human services field and two years full time or equivalent experience working with adults and children at risk.  Preferably candidate would be enrolled in a Master's Program in a related field.  Must have a valid Florida Driver's License with 6 points or less in the last 5 years.

PHYSICAL REQUIREMENTS

Must be in good physical condition with no restrictions of movement. 
Must be able to apply Therapeutic Effective Aggression Management (CARE) Techniques without limitations.
 

ESSENTIAL JOB FUNCTIONS

1.0 Provides emergency interventions, post-ventions, and appropriate dispositions for assigned clients.  Conducts emergency mental health screenings for new and existing clients in the community
  
1.1 Emergency screenings are performed in accordance with the Agency's policies and procedures for conducting emergency screenings
 
1.2 All emergency interventions are documented in writing including, but not limited to, completion of aftercare plan, safety plan, and /or transition plan; external referral sources contacted and outcome; internal referral sources contacted and outcome; and other intervention modalities utilized, e.g. crisis for the individual and his/her family.
 
1.3 Final Crisis/Screening Unit disposition for each assigned client is accurately documented in writing in accordance with policy and procedure. 
 
2.0 Point of Accountability in Coordinating Care for MCRT.
  
2.1 Provides time-limited care coordination for identified individuals using a combination of internal utilization reviews an. 
 
2.2 Responsible for the coordination of services until the individual is adequately connected to the care that meets their needs and progress towards the goals of Care Coordination are achieved.
 
3.0 Engages with Persons Served and Their Natural Support(s):
 
3.1 Ensures individuals are engaged in their current setting and if in crisis shall engage in other settings (e.g., crisis stabilization unit (CSU), homeless shelter, detoxification unit, addiction receiving facility, etc.) to establish a warm hand-off with aftercare. 
 
3.2 Works with unit supervisors to ensure frequent contact is maintained with identified individuals, continued crisis stabilization and care coordination services can occur for up to 72 hours at minim, for those individuals who agree to receive care coordination services. If the individual refuses care coordination services or they are not responding to the attempts made, the Care Manager ensures the engagement attempts and contacts are recorded in the individual's clinical record.
 
3.3 Ensures that an internal process is in place that allows for on call services to be available 24 hours, seven days a week.
 
4.0 Shared Decision-Making:
 
4.1 Models, coaches, and supports shared decision-making in care planning and service determination with the individual and family members (where applicable) and emphasizes self-management, recovery and wellness, including transition to community based services and/or supports.
 
4.2 Promotes a recovery oriented perspective that the individuals served and their family members are the driver of goals on the Care Plan.
 
5.0 Information Sharing
 
5.1 Helps develop internal protocols for use of the Recovery Oriented Care Coordination (ROCC) module to promote shared accountability.
 
6.0 Community-Based Services
 
6.1 Works with the individual to develop diversion strategies to prevent individuals who can be effectively treated in the community and divert from crisis admissions.    
 
7.0 Coordination Across the Spectrum of Health Care
  
7.1 Takes a leadership role in assessing internal organizational culture and finds ways to incorporate the core values and competencies of Care Coordination into daily practice.
 
7.2 Tracks unmet service needs and gaps and provides feedback the Team Leader.
 
7.3 Monitors access to services identified on the Aftercare/Safety Plan to ensure that individuals who require medications or other services are linked and follow through.   
 
7.4 Ensures internal capacity to assess individuals for eligibility of Supplemental Security Income (SSI), Social Security Disability Insurance (SSDI), Veteran's Administration benefits, housing benefits, and public benefits, and assist them in obtaining eligible benefits, including the use of SOAR when assessing for SSI and SSDI.
 
8.0 Culturally and Linguistically Competent
 
8.1 Monitors how effectively internal staff has incorporated into treatment plans the values, preferences, beliefs, culture, and identity of the individual served, and their community when providing care coordination.
  
8.2 Ensures there are internal protocols for meeting the linguistic needs of the individuals served.

8.3 Recommends ways that internal quality assurance protocols can address cultural and linguistic competence.
 
9.0 Tracks Measurable Outcomes and Progress towards Care Coordination Goals

 
9.1 Tracks individuals served through Care Coordination for improved outcomes in the following areas:

o    Responds to a crisis in 60 minutes or less for at least 80% of the mobile episodes.

o    Identifies ways for children with SED and ED who improve their level of functioning.

o    Monitors ways MRCT decreases/diverts admissions to crisis units.

o    Monitors formal outreach activities annually.

o    Monitors length of time from an acute care setting discharge to linkage to services in the community.

o    Other outcomes as assigned by the Team Leader.

10.0 Performs other duties as requested.
 
10.1 Miscellaneous duties are performed according to instruction.
 
10.2 All documentation is completed within the EMR system according to instruction.
 

New Horizons of the Treasure Coast, Inc.
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