Community Health Center, Inc. (CHCI). CHC is one of the country's most creative and dynamic providers of primary medical, dental and behavioral health services, and a leader in practice based research, health professionals training, and use of innovative technologies to advance health and health care.CHCI is designated as a federally qualified health center and a patient centered medical home by HRSA, the Joint Commission, and NCQA, respectively. WE deliver more than 500,000 patient visits per year from primary care hubs and community clinics across the state of Ct, all connected by technology and common standards for quality. We employ several hundred medical, dental, and behavioral health providers who are engaged in practice, teaching, and research. Our Weitzman Institute is devoted to research and practice transformation, and is recognized around the country as one of the premier research institutes focused on improving health care and health outcomes for special and vulnerable populations. In addition, the organization has developed three wholly owned subsidiaries from the original pilot developments within the Weitzman Institute, the National Nurse Practitioner Residency and Fellowship Training Consortium (NNPRFTC), the National Institute for Medical Assistant Advancement, and the Community eConsult Network.National Nurse Practitioner Residency and fellowship training Consortium, National Institute for the Advancement of Medical Assistants and the Community eConsult Network.
Behavioral Health Care Coordination is essential to the Patient Centered Medical Home Plus model. Coordinating with primary care teams members to discuss PCMH+ patients at a designated Integrated Care Team meetings (ICM). The BH Care Coordinator is responsible to establish and facilitate ICM's to focus on panel management, chronic disease management, case management, Identifying gaps in care, and transitions of care that the identified PCMH+ patients have experienced. Community Health Center has determined that a Behavioral health trained employee is best suited to fill this role.
The BH Care Coordinator is responsible for helping the care team to optimize the health outcomes of a defined sub-set of patients identified by systematic processes as having complex needs and for whom such care coordination is likely to lead to improved clinical outcomes including, but not limited to, better control of chronic illnesses and reduced transfers to higher levels of care such as hospitalization and emergency room visits. This defined panel of patients will be drawn from the identified PCMH+ patient panels of the primary care providers of the pod(s) with a preference given to those with comorbid medical and behavioral health diagnoses
The BH Care Coordinator works collaboratively with other members of the health care team including the primary care providers, medical assistants, behavioral health providers, nurses, medical assistants, Pharmacists, Access to Care staff and other ancillary staff as well as outside agencies. The main responsibilities of this position include coordinating patient care and facilitating discussion among the integrated care team to enhance planning of clinical and social services, as well as collaborating with external agencies. Provides expert feedback to the PCMH+ coordinating team on areas where staff may need additional support. Assists the team in preparing care plan.
JOB REQUIREMENTS AND RESPONSIBILITES
? BS required in a behavioral related health field
? Knowledge of and commitment to patient population/community resources
? Bi-lingual English /Spanish or English/Polish a plus
1. Supervisor Daily
2. Senior QI Data Manager weekly /monthly
3. Operation Managers daily
4. Clinical Chiefs
5. Primary Care Team members daily
6. Pharmacy Resources as needed
7. Community Behavioral Health as needed
Physical labor is minimal for this position.
VI. WORK SCHEDULE DEMANDS
This position is full time unless otherwise noted in postings.
VII. COMMUNICATION SKILLS
Excellent verbal and written skills are required. This position is highly involved with staff, providers, colleagues and community resources.
VIII. CONFIDENTIALITY OF INFORMATION
Professional standard of confidentiality of patient records and conversations
IX. SIGNIFICANT JOB FUNCTIONS
? Reviews CHC PCMH+ report to identify potential members for discussion based on risk score, utilization and comorbidities.
? Uses CHC Team Based Panel Management reports to identify all key people at the meeting. Works with supervisors and key staff to ensure staff members are available and in attendance.
? Documents using the ICM template. Maintains a tracking system to easily keep track of patients currently receiving ICM coordination services.
? Attends ICM's with each Primary Care Team
? Utilizes innovative modes of communication to engage team members in critical thinking during the ICM's
? Assists staff to identify any "navigation" issues to ensure that patients they are able to attend scheduled medical visits both at CHC and outside the agency
? Coordinates with the Operation Managers to ensure scheduling blocks fo the ICM's hosting at least one meeting per month at each site
? Prepares each patient case for presentation to the ICM team
? Track staff participation in ICM's
? Document in the Circle of Care
? Identifies BH clients who are in need of a WRAP or Psychiatric Advance Directives
X. Training requirements