Re-Entry Care Coordinator (Mobile Position-NC)

Primary Purpose of Position: The Re-Entry Care Coordinator focuses on working closely with to support individuals with serious mental illness (SMI) who are being released from a Department of Adult Correction (DAC) facility. Individuals with serious mental illness (SMI) who are being released from a Department of Adult Correction (DAC) facility will be prioritized for re-entry coordination by both the DAC and Partners Health Management. This position will ensure communication between all parties, including DAC and related divisions (health service, re-entry, community supervision) and community behavioral and physical health providers. The Re-Entry Care Coordinator will follow an individual for 90 days or until the individual qualifies for tailored care management (TCM) or other equivalent service, such as Assertive Community Treatment (ACT). This Re-Entry Care Coordinator will ensure referrals are made to all necessary services and supports including medication management, housing supports, other social determinants of health resources, behavioral and physical health care, and benefits coordination. participate in virtual and/or in person multi-sector meetings to facilitate the coordination and success of this initiative. These meetings will include DAC and DHHS representatives. This is a mobile position with work done in a variety of locations.

Role and Responsibilities:

A Re-Entry Care Coordinator is responsible for the following:

1) Ensure the following are completed in a timely manner:

a) An initial care management comprehensive assessment (completed prior to release from a DAC facility) that includes all of the required components of the TCM care management comprehensive assessment, and any necessary reassessments as care needs change development of a comprehensive care plan (prior to release from a DAC facility) which must include a 90-day transition plan. Plans must be updated as indicated based upon changes in care needs/reassessments.

b) Coordinate and participate in care team meetings before and after release from a DAC facility, as indicated

c) Care coordination activities including but not limited to ensuring physical exam, through connection to primary care, with a target initial visit with a primary care provider no later than 30 days after release; and, ensuring behavioral health assessment and connections to ongoing services with an initial behavioral health evaluation target of no more than 7 calendar days after release

d) Continuous monitoring of care needs, including medication reconciliation and coordination of medication needs

e) Individual and family supports

f) Health promotion; addressing social determinants of health

g) transitional care management

h) Referral to TCL resources (diversion, in-reach; transition) as indicated

i) If a DAC referred individual is released before the plan is in place, then the plan must be completed no more than five (5) business days after the release from the DAC facility

j) For the first 90 days, ensure at least four contacts with each recipient per month, including at least one in-person contact with the recipient. After the initial 90 days at least one contact per month with additional contacts tailored to the needs of the individual.

k) Coordinate with the DAC assigned Re-entry Social Worker on transition from the DAC facility into community services for behavioral and physical healthcare

l) Link to support systems in their community including housing and other social determinants of health resources

m) Establish or reactivate health insurance benefits, as eligible, including all eligible public benefits such as Medicaid

n) Ensure continuity of care from DAC post release based on all available information supplied by DAC and any post release assessments.

o) Coordinate with assigned community supervision officer, DAC/DHHS representatives and any relevant providers as applicable to the needs of the recipient

p) Continue for 90 days or until individual qualifies for Tailored Care Management or an equivalent ongoing care management intervention. This may include facilitating documentation submitted to NC Division of Health Benefits of SMI, or other qualifying conditions, in order to qualify for TCM if the recipient does not qualify based upon other available data sources. The 90- day timeframe is subject to renewal.

q) Maintain accurate tracking and data information for care management activities and outcomes including tracking of individuals in and out of services, those who are on waiting lists, those who need follow-up, and those on outpatient commitments

Collaboration

The Re-Entry Care Coordinator shall report monthly to the DMH Project Manager:

1) the number of referrals from DAC

2) The number of contacts per recipient per month

3) number of individuals successfully transferred to Tailored Care Management or equivalent services

4) Number of individuals not transferred to Tailored Care Management or equivalent services who have a 90-day renewal, or reason for voluntary or involuntary discharge including lost to follow up

5) The number of incident reports submitted to IRIS per month which involves the recipient

6) Number of crisis events including IVC episodes or emergency department, inpatient visits involving recipients

7) Number of justice system recidivism events

8) Reports of criminal activities

The Re-Entry Coordinator:

1) Serves as a collaborative partner in identifying system barriers through work with community stakeholders

2) Works in partnership with other LME/MCO departments to address identified

Knowledge, Skills and Abilities:

• Extensive understanding of the Diagnostic and Statistical Manual of Mental Disorders (current version)
• Considerable knowledge of the MHSU/IDD service array provided through the network of the LME/MCO’s providers
• Knowledge of LME/MCO’s implementation of the 1915(b/c) waivers and accreditation
• Highly skilled at assuring that both long and short-range goals and needs of the individual are addressed and updated, while assuring through monitoring activities that service implementation occurs appropriately
• Exceptional interpersonal and communication skills
• Excellent computer skills including proficiency in Microsoft Office products (Word, Excel, Outlook, and PowerPoint)
• Excellent problem solving, negotiation, arbitration, and conflict resolution skills
• Detail-oriented, able to organize multiple tasks and priorities and effectively manage projects from start to finish
• Ability to make prompt independent decisions based upon relevant facts, to establish rapport and maintain effective working relationships
• Ability to change the focus of his/her activities to meet changing priorities
• A high level of diplomacy and discretion is required to effectively negotiate and resolve issues with minimal assistance

Education/Experience Required:

• Qualified Professional Care Manager:
• Bachelor's degree in a human service field with two years of full-time, post-bachelor's degree experience with the population served

-or-

• Bachelor's degree in a field other than human services with four years of full-time, post-bachelor's degree experience with the population served

-or-

• Master’s degree in a human service field and one year of full-time, post-graduate degree experience with the population served

-or-

• Licensure as a registered nurse (RN) and four (4) years of full-time accumulated experience with the population served

• 
  Provisionally Licensed Care Manager:

• Current unrestricted LCSW-A, LCMHC-A, LCAS-A, LMFT-A.
• Employee is responsible for complying with respective licensure board’s continuing education/training requirements in order to maintain an active provisional license (prior to obtaining full licensure).

• 
  Licensed Care Manager:
• Current unrestricted LCSW, LCMHC, LPA, LMFT, LCAS, or RN licensure with the appropriate professional board of licensure in the state of North Carolina.
• Employee is responsible for complying with respective licensure board’s continuing education/training requirements in order to maintain an active license.

Other requirements:

• Must reside in North Carolina.
• Must have ability to travel regularly as needed to perform the job duties

Education/Experience Preferred: Above requirements

Licensure/Certification Requirements: Above requirements