CTT is mandated to provide service to those individuals within the mental health system who present the greatest degree of severity of symptomatology as evidenced by their multiple physical, psychiatric, and legal conditions, extensive use of services, and lack of follow through with treatment. This population requires the highest level of medical necessity as defined by the state Adult Environmental Matrix. The Teams that provide multidisciplinary clinical review and assessment of individuals who may be young adults, heavy users of service, or actively involved in the criminal justice system and may also have co-occurring behavioral health diagnoses are generic and specialized. The Case Management Specialist provides case management supports based on the Community Support Program of Philadelphia with assisting the individual in developing skills required to enhance his/her comfort and abilities to function as a productive member of the community. The CM Specialist takes the lead in one of four areas of specialty: vocational, housing, D&A or forensic, and works in collaboration with primary case manager to identify goals, develop, implement and monitor the service plan. The CM Specialist will ensure that the mission, goals and philosophy of the CTT are operationalized within the team.The incumbent works with individuals in their community environment assisting them in understanding, acquiring and maintaining independent living skills in the areas of: (a) their daily living situation; (b) interpersonal skills and social support/network building; (c) leisure and recreational support/skill development; (d) maintenance and enhancement of physical and mental needs; (e) obtainment of benefit entitlements and the skills to manage same; (f) vocational and educational needs.
Duties and Responsibilities:
Assesses individual’s strengths, needs, and wants utilizing instruments to operationalize data in the consumer’s behalf. This includes completion of Strengths Assessment and client-centered Unified Personal Plan for each assigned individual, involving all treatment team principals for comprehensiveness.
Works collaboratively with multidisciplinary team internally on daily basis, and external as needed to ensure coordination between systems; provides linkage with primary care physician to ensure integration of medical and psychiatric service needs; maintains linkage with CBH to minimize person’s reliance on acute services.
Periodically completes Environmental Matrix to determine level of care need, and delivers services according to individual’s need, ensuring appropriate frequency of contact.
Monitors individual’s progress toward attainment of identified goals through monthly Linkage Meetings to review same; goals should be short term, measurable and obtainable. Plans should be updated according to regulatory standards, and all related activities documented on appropriate agency forms.
Liaisons, communicates with, and represents individual via telephone contacts and face-to-face meetings. This includes regular contact with individual and community service providers in order to respond to individual’s changing needs, assist in problem resolution and provide advocacy mechanism to ensure that needs are met.
Participates in in-patient treatment team and discharge planning meetings; monitors individual’s treatment and progress during hospitalizations.
Maintains and updates community resource file on housing, vocational, D&A and forensic resources; assists individual in accessing same, and provides necessary training around use in order to facilitate individual’s ability to use resources independently; attends DBH sponsored training on vocational and housing resources and shares information with team; participates in internal specialist meetings as scheduled.
Accompanies individual to appointments (financial entitlements, housing, ed/voc sites, court, probation, etc.) to provide support and assistance.
Provides training to individual on use of public transportation, job seeking skills, the identification and use of social and recreational resources, etc.
Participates in daily team meetings and Clinical Care Meetings to problem solve around persons needing extensive services for specific times; attends Open Forum and other required agency meetings.
Attends in-service and other trainings in order to meet mandated training hours.
Completes required paperwork documentation in timely manner.
Assists individual to increase community tenure, enhance quality of life, and attain highest level of independent functioning.
Provides after hours work including: a) participation in weekly on call rotation schedule to permit 24 hour/7 day a week access to service; b) and participation in evening and weekend shift work schedules required for delivery of services to CTT’s assigned caseload.
Must have good verbal/written communication skills and work well with people; good, creative problem solving skills; ability to work independently, and be flexible/adaptive in handling changing priorities in a fast paced work environment; computer skills preferred.
PMHCC - 15 months ago