SUMMARY
This is a full-time non-exempt position primarily responsible for the assessment of client functioning and the development, preparation, and implementation of a comprehensive Targeted Case Management Plan for individuals preparing for discharge from or recently discharged from the State Mental Hospital (SMH) system or discharged from a community inpatient psychiatric facility. Responsible for monitoring all services received by TCM clients, resource development, service linkage, crisis intervention services and client advocacy. Works as an interdisciplinary team member. Work assignments will be discussed at bi-weekly planning meetings. Goals and objectives will be developed, and priority assignments identified. Maintains all TCM records and other relevant paperwork accurately and promptly. Primary work hours will be Monday through Friday, 8:30am to 4:30pm with a 30-minute lunch (37.5 hours/week) unless otherwise agreed upon.
Compliance:
As with all WCSI positions, it is the expectation that employees adhere to WCSI, County, State and Federal guidelines, regulation, policies, and laws which govern the business and service of WCSI.
This position requires the employee to perform their daily duties and responsibilities in an unstructured work environment.
ESSENTIAL DUTIES AND RESPONSIBILITIES
Includes the following, (other duties may be assigned as deemed necessary by management):
Specialized Duties:
This position will coordinate care with the State Hospital Liaison and/or Community Hospital Liaison for individuals preparing for discharge within the last thirty (30) days of the anticipated SMH or Community Inpatient Psychiatric Facility stay. Acute TCM shall link the client with housing and benefits and assist the Liaison with setting up treatment services and arranging for the client’s departure from the hospital. Acute TCM should monitor the client closely during the initial ninety (90) days, with more frequent visits than traditional TCM to ensure continuity and assist with prevention of recidivism. The caseload will be targeted at new or recent discharges and will have a length of stay dependent on the client’s ability to stabilize in the community to the point where a traditional TCM may take over the case.
Case Management Activities:
Assess clients need utilizing the Environmental Matrix and Strength Based Assessment (SBA), client and/or collateral interviews, and reviews of clinical and social information. Needs assessment will consider current and historical information, with emphasis on precipitating factors to deteriorate functioning. Develops, prepares, and implements a comprehensive Targeted Case Management Service Plan which includes short- and long-term goals/outcomes based on client, provider and TCM team input. Goals and outcomes are strength oriented and clearly operationalized to facilitate assessment of progress. Outcomes will be directed towards reduced hospitalization, independent living, improved vocational/educational status and social support. Conducts regular, documented reevaluations of client progress. Ensures face-to-face contact with the client based on program requirements, working on a variable schedule as assigned by supervisor.
Crisis Intervention Activities:
Participates in a rotating system to ensure that 24-hour crisis services are available. Responds to both face-to-face and telephone requests for intervention. Evaluates clients and works with Crisis Intervention services to arrange for urgent psychiatric care, if needed. Ensure that all alternatives to hospitalization have been explored.
Monitoring and Coordination Activities:
Monitors all services received clients by reviewing cases; meeting with family, significant others, relevant providers, advocates, and attorneys; and attending TCM team meetings. Participates in interdisciplinary and psychiatric treatment team meetings as required. Ensuring client needs are met through utilization of natural support and other social services. Investigate new resources and communicate with respective providers on the client’s behalf. Maintains the current directory of community resources. Assist clients with identification, linkage, access, and coordination of these resources.
Advocacy Activities:
Advocates for the client to ensure responsiveness from natural, community, generic and specialized services. Advocacy includes providing information, removing barriers, and creating options and resolving problems.
Case Documentation:
Maintains Targeted Case Management records, charts of contacts with clients and collateral contacts. Updates forms as needed. Reviews charts for compliance with regulations. Prepares for annual record audits by the county and state. Efficiently completes paperwork and other program related material. Consistently maintain service provisions in accordance with the department standard, as established by WCSI.
Professional/Technical Responsibilities:
Extensive knowledge of theories, principles, and techniques related to service provided. Ability to establish/maintain effective working relationships with clients, associates, and agency personnel. Knowledge of community resources and ability to facilitate coordination activities. Ability to prepare clear, concise reports and to communicate effectively, both orally and in writing.
QUALIFICATIONS
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.
Education and/or Experience:
Master’s degree in social work, psychology, rehabilitation, activity therapies, counseling or education and 3 years’ mental health direct care experience or:
Bachelor’s Degree which includes or is supplemented by at least 12 college credits in sociology, social welfare, psychology, gerontology, criminal justice, or other related social science AND three years of direct experience in behavioral health, of which two years must be experience working with or providing services to adult individuals with serious mental illness or to children with serious emotional disturbance or at risk for same. Experience as a case manager is preferred, but not required or:
Bachelor’s degree in nursing and 3 years of direct mental health care experience.
Experience with clientele diagnosed with serious and persistent mental illness is preferred.
Language Skills:
Strong Interpersonal skills, effective oral and written communication skills.
Certificates, Registrations, Licenses:
Valid PA Driver’s License, Proof of Valid Auto Insurance, Act 34 (Criminal Record), and Act 33 (Child Abuse) and FBI Clearance. There will be monthly screenings of PA Medicheck List, LEIE (List of Excluded Individuals/Entities) and SAM (System for Award Management).
Other:
This position requires the availability and utilization of the employee’s personal vehicle, for purposes of transportation to and from work appointments. Transportation of clients in personal vehicles is not permitted, as agency vehicles are available for this purpose.
As with all WCSI positions, this position will adhere to all random drug screening requirements, as set forth by WCSI Policy.
ENVIRONMENT, PHYSICAL and MENTAL CONDITIONS
Physical/Mental Demands:
While performing the duties of this job, the employee is regularly required to operate a motor vehicle, sit, stand, walk, bend and lift objects of up to 10 pounds. The employee regularly uses a computer, phone, fax, copier, and other essential office equipment to carry out daily work assignments.
Substantial problem solving in response to urgent/emergency situations, which may require immediate action. Ability to apply principles of leadership and management in daily practice.
Work Environment:
While performing the duties of this job, BH Case management is provided as needed in the place where the client resides or needs the service. Case management is a community-based service and offers service in the client’s home, community center, and place of worship or treatment center. Case managers will provide linkage, monitoring, access to services; provide assessment and service planning, problem resolution and informal support network building for clients on their caseload in a client driven fashion where and when it is needed. Exposure to outside weather conditions will exist. The noise level in the work environment is usually moderate. The work environment for this position requires the employee to have the skills and ability to perform their daily job duties and responsibilities in an unstructured work environment.
REASONABLE ACCOMMODATION
It is WCSI’s business philosophy and practice to provide reasonable accommodation, according to applicable state and federal laws, to all qualified individuals with disabilities.