The Care Coordinator is responsible for providing service coordination of patients with chronic mental illness, substance abuse, and physical health conditions. The goal of care coordination is to reduce unnecessary contacts with emergency departments and unnecessary inpatient hospitalizations while removing barriers to outpatient services and healthy outcomes.
Essential Duties and Responsibilities:
· Provide appropriate linkages, referrals, coordination, and follow-up for patients to services and supports, including referrals and linkages to long term services and supports.
· Provide health care appointment scheduling for patients to mental health, substance abuse, and physical health providers.
· Ensure patient has adequate transportation to and from appointments, including transporting patients directly as needed.
· Participate in hospital discharge processes and communicate with other providers and family members.
· Communicate and collaborate with hospital emergency department staff to ensure the coordination of patient care and treatment.
· Communicate with the patient’s care team, including providers at HRDI, Friend health, and any other community based service provider that they may be affiliated with for continuity of care.
· Assist patients in obtaining necessary medications and coordinating with their care team to increase medication compliance.
· Serve as a community educator by providing health and social determinant information to relevant organizations and groups.
· Work closely with community resources and organizations in coordinating client services.
· Advocate for patients who may be vulnerable or need additional support.
Additional Duties and Responsibilities:
· Respond to hospital admission, discharge and transfer (ADT) alerts in real time of project enrolled or eligible individuals
· Engage with patients in-person at relevant hospitals, during hospitalization focusing on: reasons for the emergency department visit or hospitalization, reinforcing care management plan of care, updating information for medical chart and related MCO, plan of care post-discharge, and goal setting.
· Complete assessments as appropriate, such as the Health Risk Assessments, initiate Care Plan, TOC Bundle, and others as needed.
· Educate and support patients in health literacy, medication management, plan for follow-up and ongoing care, signs and symptoms of worsening conditions, functional or social needs, home and community-based services, advance directives, and other issues as identified.
· Interface with hospital care team including nurses, social workers, case managers, hospitalists, and other staff responsible for utilization management and discharge planning. Engage with other stakeholders such as the patients’ family support network and external organizations the patient accesses for collaboration on patient success post-discharge.
· Assess patient readiness for change and work with care team to ensure patients discharges to proper services, specifically for mental health and substance use treatment. Identify and address barriers to assure an efficient and complete transitions of care.
Experience and Education:
· High School Diploma
· Previous experience working in a team environment
· Knowledge of community resources
· Experience in working with adults diagnosed with multi-occurring disorders.
· Bachelor’s degree in human services field
· At least 1 year relevant experience working with adults experiencing mental illness.
· Social Skills
· Problem solving
· Quality management
· Safety and security
· Interpersonal skills
· Oral communication
· Written communication
Human Resources Development Institute, |Inc.
Why Work Here?In 1974, Dr. Vincent Bakeman and Mrs. Doris Lomax founded a not for profit organization what is now known as Human Resources Development Institute, Inc. (HRDI). The organization was formed as a result of a lack of services in the lower socio-economic communities of color in Chicago, IL and Alabama. Today HRDI continues to serve those same under-served communities, and many other disadvantaged populations. HRDI provides medical, mental health and substance abuse and various other services and programs.
Collectively as a team, HRDI is providing service, hope, encouragement and empowerment to a deserving communities in need.