Care Coordinator (Foley Adult Outpatient) - AltaPointe Health

Certified Community Behavioral Health Clinics (CCBHC’s) seek to improve the behavioral health of their communities by: providing outpatient mental and substance use disorder services; advancing integration of behavioral health with physical health care; assimilating and utilizing evidence-based practices on a more consistent basis; and promoting improved access to high quality care.

General Responsibilities:

• Assess and re-evaluate patient needs utilizing information from EHR and additional tools as appropriate to determine patient needs and preferences and communicate those to all treatment participants
• Create an Integrated Care Plan in conjunction with the patient and/or caregiver
• Ensure the patient understands the Care Plan and is equipped to follow it
• Identify and address all barriers that might impede the ability of the patient to care for themselves
• Assemble appropriate team of professionals to assist in meeting patient needs, organize patient care activities and share information among all participants
• Assist the patient/caretaker in navigating the health system while addressing any insurance coverage issues
• Update assessment and care plan at least every 90 days
• Utilize the Integrated Care Plan to drive all activities and services
• Provide information and feedback in daily Huddles regarding needs, plans/interventions/results
• Research ways to meet needs and put action steps in place, monitor for progress
• Advocate on behalf of the patient
• Follow up regularly with patient to ensure needs are being met and identify any changes to patient circumstances, any compliance concerns
• Consult with treatment team when noncompliance is found
• Provide training on disease management and healthy living skills
• Provides initial Diabetes Care Introduction
• Provide support and education for patient and their support system
• Facilitate securing/providing medical records when patient is in the hospital, ED, etc.
• Track and support patients when they obtain services outside the practice.
• Follow-up with patients within a few days of an emergency room visit or hospital discharge.
• Communicate test results and care plans to patients/families.
• Collaborate and consult with staff members and outside sources in the delivery and arrangement of services
• Demonstrates the ability to recognize the elements of a crisis state and knows how to deescalate or resolve the situation
• Effectively demonstrates the application of adult specific competencies

Supervision and Consultation:

• Seek supervision and consultation as needed
• Accept and employs suggestions for improvement
• Actively works to enhance skills

Clinical Record Keeping:

• Document in a timely fashion per AltaPointe policy
• Document in a clear and concise manner.
• Document legibly

Courteous and respectful attitudes towards consumers, visitors, and co-workers:

• Treat patients with care, dignity, and respect
• Respect privacy and confidentiality
• Assist others as needed
• Adopt a teamwork approach with coworkers

Administrative and Other Related Duties as Assigned:

• Actively participates in Performance Improvement activities
• Actively participates in AltaPointe committees as required
• Completes assigned tasks in a timely manner
• Follows AltaPointe policies and procedures
• Attends appropriate in-services training and other workshops

Bachelor’s degree in a behavioral health or social services related discipline preferred. HSD or GED with 2 years of experience working with individuals with psychiatric, substance use, and/or developmental disabilities required in lieu of degree. Must meet all driving requirements.

Knowledge in adult specialties, outlined below, to be attained within six (6) months of employment:

• Psychiatric disorders in adult populations
• Chronic medical conditions
• Trauma Informed Care
• Cultural diversity
• Social determinants of health
• How to administer and utilize basic assessment tools to assess needs and create an Integrated Care Plan
• Resources available to meet the needs of patients based on payor source
• Utilizing electronic health records
• Behavior management, crisis intervention and interventions common to acute psychotic consumers, as well as, to non-violent crisis intervention practices.