Job Information
Trinity Health Health Home Plus Transitions Coordinator in Syracuse, New York
Employment Type:
Full time
Shift:
Description:
MISSION STATEMENT:
We, St. Joseph’s Health and Trinity Health, serve together in the spirit of the Gospel as a compassionate and transforming healing presence within our communities.
VISION:
To be world-renowned for passionate patient care and outstanding clinical outcomes.
CORE VALUES:
In the spirit of good Stewardship , we heal by practicing: Compassion through our kindness, concern and genuine caring. Reverence in honoring the dignity of the human spirit, Excellenc e in expecting the best of ourselves and others; Integrity in being and speaking the truth.
RELATIONSHIP-BASED CAREGUIDING PRINCIPLES:
Caring and healing practices are found in relationships, communication and the hospital and ambulatory settings. Patients are actively involved in their care and experience a therapeutic relationship with the caregiver.
Patient care is designed to meet patient and family needs while taking into account the unique needs of each patient. These values are consistent in practice and include patient advocacy, safety and education.
Teamwork promotes clinical excellence and is rooted in effective communication, accountability and continuity of care and respect for coworkers.
Caring leaders create an environment in which caring relationships happen. These leaders emerge from all levels of the network helping to create a shared vision reflecting the mission, vision and values of St. Joseph’s.
Positing: We are looking for an energetic individual to join our Team! The ideal candidate will be someone who exercises compassion and dedication to serving the High-Need Seriously Mentally Ill population. The Health Home Plus (HH+) Transitions Coordinator is responsible for acting as a bridge between health care providers, social care providers and individuals in the community to promote health, reduce disparities and improve service delivery. Supporting individuals as they transition across the care continuum strengthens the connection with their providers and resources, which ultimately helps them to reach their potential. This includes the promotion of preventative care to reduce preventable emergency room and inpatient utilization, as well as an opportunity to address any social influencers of health
Position Summary:
The HH+ Transitions Coordinator will develop a professional and trusting relationship with the High-Need Seriously Mentally Ill (SMI) population and community providers to ensure coordination and collaboration of services supporting positive outcomes. This is accomplished by providing community visits to patients discharged from the Inpatient Behavioral Health Unit or Crisis Unit at the Hospital and employing an empowerment approach in coordination with health and social care providers. This "bridge" from the hospital to the community ensures a warm handoff and allows for any barriers to be addressed in real time. The goal of the community based visit is to review the discharge instructions with the patient, repeat the “teach back” information protocol, identify any barriers to following the discharge plan (to include follow up appointments, prescriptions, transportation to appointments, etc.) and ensure that the patient has necessary follows up visits. Time is split between working in the community conducting visits, working in the hospital and local shelter. This position will also support a small caseload of individuals enrolled in the program who are High-Need with Serious Mental Illness.
Education & Experience Requirements:
Bachelor’s degree in Human Services* with minimum of two years’ experience, or a Master’s Degree in Human Services*, with one year experience, working with individuals diagnosed with Mental Illness, Substance Use Disorders, or Developmental Mental Disabilities providing direct linkage to community supports is required.
A Bachelor’s degree in an unrelated field with at least five years of experience, working with clients with Mental Illness, Substance Use Disorders, or Developmental Disabilities.
Previous discharge planning, counseling, home care, and substance abuse treatment experience is desired.
Strong writing and communication skills are required, as well as knowledge of working with community agencies and managed care representatives.
Experience working with a diverse population and a strong understanding of multicultural issues is preferred.
A valid and insurable NYS Driver’s License.
**Human Services Fields include: Social Work, Psychology, Sociology, Nursing, Rehabilitation, Counseling, Community Mental Health, and Child & Family Services.
Job Requirements:
The ideal candidate will demonstrate:
Extensive planning, organizational skills, and excellent communication with collateral contacts, referral and networking.
Ability to interview patients to assess decision making, coping skills, and barriers to managing their healthcare needs.
Adhere to policies and procedures as developed by the director of the department.
Be comfortable working with individuals actively experiencing behavioral health symptoms.
Must be able to work closely with others and work with members in both routine and stressful situations related to the their medical conditions and social influencers of health
Ability to work independently, setting priorities to coordinate care plan efficiently. As well as the ability to work in a team environment
Requires the ability to drive, must possess a valid driver’s license.
Effective behavioral and educational strategies, including but not limited to, motivational interviewing, teach-back method and self-management support.
A working knowledge of entitlement programs (SSI, SSDI, Medicare, Medicaid, and Public Assistance) and community resources strongly preferred.
Strong Computer Literacy.
Prior experience with care management/coordination is preferred.
Responsibilities:
Provides support, empowerment, education and identifies support needed for patients and their families. Conduct an assessment for the establishment of a person-centered care plan that coordinates and integrates a comprehensive array of a member’s needs and services in collaboration with an interdisciplinary care team. Respect members right to self-determination and providing creative guidance to members to support their care plan. Assist patients through the healthcare system by acting as a patient advocate and navigator to support reduction in readmissions and strengthen connectivity to community supports. Links individuals to community resource to meet basic needs that influence health (i.e.: Housing, food, transportation, child care, etc.). Maintain weekly contact with Members, collaterals, care team participants, etc., to support continuity of care and the needs as identified in the Plan of Care. Promotes clear communication amongst care team and treating clinicians by ensuring awareness regarding patients care plans. Complete all documentation within required timeframes (as defined in Policies). It is the expectation that all interactions with or on behalf of a patient be documented in the electronic health record, and be unique and detailed. Be an engaged team member who supports colleagues and department needs. This includes participation in team and department meetings; as well as supervision. Gather information from the “community” and from “high need patients” regarding barriers to health and access to services, and communicate these needs to the Director of the Department. Participate in and / or initiate provider meetings as needed to discuss the status of the member and any factors that may be serving as barriers to success.
Pay Range: $22.25-$32.30
Our Commitment to Diversity and Inclusion
Trinity Health is one of the largest not-for-profit, Catholic healthcare systems in the nation. Built on the foundation of our Mission and Core Values, we integrate diversity, equity, and inclusion in all that we do. Our colleagues have different lived experiences, customs, abilities, and talents. Together, we become our best selves. A diverse and inclusive workforce provides the most accessible and equitable care for those we serve. Trinity Health is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, status as a protected veteran, or any other status protected by law.
Our Commitment to Diversity and Inclusion
Trinity Health is a family of 115,000 colleagues and nearly 26,000 physicians and clinicians across 25 states. Because we serve diverse populations, our colleagues are trained to recognize the cultural beliefs, values, traditions, language preferences, and health practices of the communities that we serve and to apply that knowledge to produce positive health outcomes. We also recognize that each of us has a different way of thinking and perceiving our world and that these differences often lead to innovative solutions.
Our dedication to diversity includes a unified workforce (through training and education, recruitment, retention, and development), commitment and accountability, communication, community partnerships, and supplier diversity.
EOE including disability/veteran