Health Home Case Manager

1. Promote a safe, cooperative, and professional health care environment to ensure optimum patient care (as per HR Policy 113c).

2. Adheres to all hospital policies, procedures, rules, and regulations, including but not limited to, absenteeism, ETIME, cellular telephone usage, dress code and rules of conduct.

3. Makes Customer Service a priority, treating customers (patients, visitors, and co-workers) in a professional manner exercising courtesy and tact. Effectively communicates with patients and others about SBH services in their area(s) of expertise or responsibility and ensures that concerns, questions, or issues reach the right person(s) in SBH in a timely fashion.

4. Demonstrates the standards of performance and behaviors consistent with the DRIVE to Patient-Centered Excellence.

5. Gather information and conduct outreach, intake assessment, and reassessments.

6. Complete a comprehensive assessment for each assigned patient, after discussion with the patient, family member, as well as review of patient’s medical records. Conduct HARP and other assessments as required.

7. Complete a patient centered Plan of Care (POC) based on the comprehensive assessment, within the required time, to address patient health and social needs. Includes HARP/HCBS where relevant. Update the POC at regular intervals and/or based on changes in patient’s status

8. Provides care management to an assigned panel of patients including Health Home low acuity, medium acuity, and high acuity as well as Health Home Plus patient.

9. Participate in case conference with Health Home team including, Case Managers, treatment provider, and other members of a multidisciplinary team.

10. Assesses patient eligibility for relevant programs and undertakes relevant documentation to ensure patient access to need services. Ensures entitlements, insurance, and benefits are in place.

11. Develop service plans and resolves barriers to effective service utilization.

12. Actively participates in training opportunities to stay current or develop skills with the changing systems including Health Home Plus trainings.

13.Monitor client’s progress in utilizing services (appointments, treatment, medication, etc.) through telephone and direct contact.

14. Document service information in databases and use electronic systems to track participant activities.

15. Conduct outreach and other contact activities, as needed, to help the patient remain engaged in care, and close relevant gaps in care. Focuses efforts on improving health conditions.

16. Accurately record all services provided in the patient’s electronic health record or other relevant electronic system, as required by BAHN.

17. Identifies and relays pertinent psychosocial and health related issues to Social Worker, Registered Nurse, and/or PCP for interventions.

18. Responds to notification of inpatient admissions of emergency department visit to assess the situation and provides necessary interventions.

19. Maintains a caseload-tacking toll to manager effectively all aspects of the POC and to ensure timely completion of required elements of the POC.

20. Assists patients with securing medical and social service appointments, reminds patients of pending appointments, and follows up on missed appointments. Provides ongoing education regarding adherence to medical appointments and treatment plans to help the patient maintain optimal health and meet social needs. Conducts site visits and home visits as needed and assigned.

21.Consistently treats patients with empathy and respect and conducts oneself in a professional manner.

22. Attends ongoing trainings to develop new skills and keep abreast of current regulations and other developments in health care

23. Coordinates and sustains connection of patients with appropriate SBH resources including Health & Wellness, Population Health Home.

24. Use SBH translation services, as necessary.

25. Performs other related duties at the discretion of the management

26. Attend scheduled department and division meetings and participate as appropriate.