Case Management Responsibilities: As a member of the patient care team, provides case management to primary care panels by addressing social determinants of health. Meets regularly with each patient as needed. Conducts thorough assessments with each patient to ensure that supportive and appropriate plans are developed. Creates housing and employment plans with each patient based on their goals related to employment, volunteer work, education, economic self-sufficiency, and housing. Assists patients with implementing and making progress on job and housing search plans. Writes an individualized resume with each patient and may conduct mock interviews with patients in order to provide constructive feedback. Assists with cover letters, thank you notes, and employment and/or housing applications. Follows up with patients regarding job and housing application submittals and other aspects of their search. Encourages housing options that are sustainable and supportive based on special needs and maintenance of sobriety. Connects patients to other community resources such as legal resources, CalFresh, CalWORKs, general assistance, transportation resources, and other needs. Supports patient in addressing other social needs and resources.
Workshop/Support Group Responsibilities: Facilitates a daily meeting with patients focused on opportunities for housing, education, resources, and employment. Teaches workshops on topics such as job searching, interviewing, legal resources, housing, money management, and health and wellness. Facilitates other special workshops as necessary.
Patient Development Responsibilities: Provides counseling and support around addressing all social determinants of health. Connects patients to work opportunities or training programs and other resources when appropriate. Ensures that each patient’s employment goals are in line with the larger goal of economic self-sufficiency. Observes patient performance and provides positive and constructive feedback to build professional behavior.
Care Coordination Responsibilities: Huddles daily with the multidisciplinary health care team to identify and address needs of the primary care panel. Works in conjunction with the other patient care team members to identify and address barriers to care, as well as short term needs, and long term goals. Participates in case conferencing at provider meetings, as well as the integration meeting, to coordinate care needs. Supports patients in overcoming identified barriers to care, as well as care plan adherence to improve health outcomes.
Treatment Liaison and Community Collaboration Responsibilities: Participates in and organizes case conferences with department and clinical staff when necessary, both within the organization and outside of the organization observing patient privacy rights. Connects appropriate patients to SSI advocacy programs and Department of Rehabilitation. Provides referrals to community housing and related resources. Collaborates with community organizations, property management companies, training programs, employers, and government agencies to provide relevant resources or services to patients. Attends networking functions, meetings, and conferences as necessary.
Program Development and Research Responsibilities: Provides assistance in development and implementation of Resource Center services. Plans, implements and facilitates special workshops/activities/events. Identifies, organizes, maintains and disseminates information on a wide variety of economic supports, employment and training opportunities, legal and money management resources, and housing options in the Bay Area (e.g. shared, supportive, subsidized, clean and sober, moderate income housing, etc.). Finds low-income and affordable housing opportunities.
Administrative and Documentation Responsibilities: Maintains accurate records (group and individual sessions, significant patient activities, detailed notes of patient interactions) in eClinicalWorks and verifies necessary information in Welligent. Attends weekly internal staff meetings and other departmental meetings as required. Meets productivity and compliance guidelines of the program. Generates reports as directed.