GENERAL DESCRIPTION: Community Support is a rehabilitative and support service for individuals with primary diagnosis consistent with a serious and persistent mental illness (CSMH) or a primary substance use disorder (CSSA). Intention of the level of care is to support the individual in maintaining stable community living, prevent exacerbation of mental illness, maintain abstinence, and prevent admission to higher levels of care.
Goodwill has a contractual arrangement with Region 3/Region 4 and the Department of Health & Human Services: Division of Behavioral Health.
ESSENTIAL JOB FUNCTIONS: (NOTE: Qualified persons with disabilities are encouraged to apply. Reasonable accommodation will be made.)
- Develop the individualized treatment plan: utilizing a strength-based assessment to develop a treatment/rehabilitative/recovery plan with the individual integrating the individual’s strengths/needs, considering community, family and other supports, stating measureable goals and specific interventions, and includes a documented discharge and relapse prevention plan. Facilitate the treatment team meeting collaborating with all members to building an effective support system.
- Facilitate and track progress of the treatment plan: Provide interventions, in a trauma informed manner, to facilitate active rehabilitation. Interventions may include skill building in activities of daily living, symptom recognition, medication compliance, relapse prevention, social skills, budgeting, and other independent living skills that enable the individual to reside in their community.
- Provide crisis management: provide therapeutic support and intervention in time of crisis and develop a crisis relapse prevention plan.
- Adhere to program documentation policies & procedures: Track data or client demographics, outcomes, service providers, referrals, goal progress, level of engagement in recovery, and related information, etc. in the participant’s electronic file. Complete documentation in a timely manner as required, including the development of the ITTP, goal review process, and progress notes. Competently present each case’s medical necessity for authorization and reauthorization to Managed Care Organizations to ensure the service provided will be a billable service and within the appropriate level of care.
- Provide face-to-face service coordination and case management community-based activities: Provide and document required face-to-face community-based contacts on a monthly basis, per contract specification (Medicaid and Region requirements) and budgeted unit utilization. Provide active rehabilitation and support interventions with focus on activities of daily living, education, budgeting, medication adherence, and self-administration, relapse prevention, social skills, and other independent living skills that enable the individual to reside successfully in their community. Assist in admission and discharges to ensure continuity of care, when hospitalization or treatment with other facility is needed.
- Clinical Supervision: Actively participate in routine (minimum of monthly) Clinical Supervision meetings to review the treatment plan, determine appropriate level of care, evaluate ongoing medical necessity, and explore/implement recommendations per care reviewed. Complete chart audit worksheets to track the documentation requirements.
- Competency in diagnostics and treatment options: Be knowledgeable on diagnostics and medications, including treatment options, reasons for taking the medications, possible complications/side effects, etc.
- Client-centered approach that focuses on exploring and resolving ambivalence and centers on motivational processes within the individual that facilitates change that includes identification, examination, and resolution of ambivalence about changing behavior.
- Use of Motivational Interviewing skills and approach that focuses on building rapport between case worker and participant that encourages participant autonomy that evokes change. Change is supported in a manner congruent with the participant’s own values and concerns and Recovery Vision.
- Motivational Interviewing skills and strategies are used to evoke the “MI Spirit” (Expressing Empathy, Support Self-efficacy, Roll with Resistance, Develop Discrepancy); include OARS, Affirmation, Reflections and Summaries.
- Effective team communication: Work effectively with participant’s professional affiliates, i.e. therapist, medication provider, guardian, etc. Be responsible for communicating necessary information to the professionals in a timely and respectful manner. Participate in admission and discharge planning with hospital/treatment center staff to assure that proper continuity of care occurs.
- Adhere to licensure and/or contract requirements: Be knowledgeable of CARF Requirements, Medicaid regulations, and Division of Behavioral Health’s Service Definitions and assure that standards are being met. Comply with state regulations and guidelines to assure future certification of the program.
- Comply with transportation policies and procedures: Follow all state and agency rules and regulations when transporting self and/or a participant. Travel is required for business purposes.
- Adhere to confidentiality policies and procedures: Process all information in a professional and confidential manner, following HIPPA standards of conduct.