Clinician Job at Commonwealth Care Alliance
Commonwealth Care Alliance's (CCA) iCMP Plus ACO inter-professional teams are responsible for providing primary care and care management to a specific panel of high risk, Medicaid ACO eligible, non-CCA patients. This patient group is made up of individuals with significant medical, behavioral, and social complexities that require intensive case management. This cohort of patients belong to outside organizations that are contracted with CCA to provide this complex care.
The Sr Clinician Behavioral Health iCMP Plus functions within and is an integral part of an inter-professional team. This team is responsible for the care coordination and care delivery of a panel of Medicaid ACO patients. The Sr Clinician Behavioral Health iCMP Plus ensures that this defined panel of patients receive the highest quality, behavioral health care within the context of a patient centric individualized plan of care. The Sr Clinician Behavioral Health iCMP Plus has the opportunity to use evidence, clinical skills, education, and training to influence the clinical outcomes of the Partners ACO patients by impacting the frequency and duration of acute psychiatric hospitalizations and community tenure through assisting to provide optimal treatment for severe and persistent mental illness, closing of quality gaps, and optimizing SUD treatment.
As an integral part of an Interprofessional Care Team and based on the fluctuating needs of a defined panel of patients, the Sr Clinician Behavioral Health iCMP Plus will engage in regular assessments, visits at regularly scheduled intervals, and conduct acute visits to ensure that members' Plan of Care is comprehensive and addresses significant medical, behavioral, and social needs.
The Sr Clinician Behavioral Health iCMP Plus will identify gaps in patient care and unmet needs. The BHS will coordinate with the iCMP Plus NP and RN along with the PCP (Primary Care Provider), Community BH, and social supports to identify areas of opportunity, as well as defined resources, and will work in coordination with the team to implement the care plan. The Sr Clinician Behavioral Health iCMP Plus will engage in direct delivery of Behavioral Health Care for identified patients who are in need of bridge therapy while awaiting a referral to a network Behavioral Health provider. There is also opportunity for the Sr Clinician Behavioral Health iCMP Plus to provide long term support for those with the most significant behavioral health needs and patients with severe and persistent mental illness.
The Sr Clinician Behavioral Health iCMP Plus will have an ability to engage with patients with identified or rising risk of Substance Use Disorder, and work with the interprofessional care team to ensure that patients are appropriately referred for addiction treatment.
The Sr Clinician Behavioral Health iCMP Plus Role reports to a BH Manager or BH Director with a dotted line to the iCMP Plus Clinical Manager.
What You'll Be Doing:
- Performs episodic urgent visits to ensure that patients are given timely and appropriate behavioral health support and care to avoid emergency room or hospitalization.
- Facilitates and/or delivers preventative care and behavioral health services to patients according the guidelines deemed appropriate by Partners Healthcare System and CCA Clinical Leadership. Guidelines may vary based on the individual make-up of the patients and is based on age, co-morbidities etc.
- Identifies and initiates a plan to resolve areas of opportunity to meet Key Performance Indicators (KPI's).
- Review members' quality gaps prior to every visit and collaborate with care team to close these gaps.
- Provides scheduled visits to conduct BH assessment and follow up visits for the management of co-morbid BH complexity and substance use concerns.
- Liaises with iCMP Plus Care Team members and community-based PCPs/ Specialists and community BH providers as needed.
- Documents all activities and results using the Electronic Medical Record, in an effective manner.
- Provides recommendation to Care Team as to best strategy in managing patients based on psychological drivers for maladaptive behaviors.
- Provides members with psycho-social, mental health, substance use and cognitive assessments as needed
- Performs crisis and risk assessments, interventions and develops a crisis plan.
- Collaborates with community vendors who are supporting patients mental health and psycho-social needs
- Performs bridge therapy to patients and ongoing treatment.
- Maintains a connection to community services and on-going care coordination with community providers
- Researches and provides community psych resources.
- Determines member behavioral health needs and potential solutions through case conferences and in person assessments.
- Performs crisis assessment and referrals to CSU and inpatient facilities as needed.
- Has training and knowledge of CSU's and may be required to cover units as needed.
- Is able to identify SUD needs, and make appropriate referrals for treatment and follow up.
- Is Required to participate in the BH On-Call Rotation
Secondary Duties & Responsibilities
- Participates in weekly Interprofessional Care Team meetings.
- Facilitates family meetings and participates in discharge planning meetings.
- Provides patient education on substance use disorder and mental health concerns.
- Assists clinical teams in evaluation of a patient's need for behavioral health services.
- In accordance with CCA policy under the Behavioral Health group, takes after hours and weekend calls, including in-person response on weekends.
- Participates in Team Case Review.
- Participates in Risk Management meetings as needed.
- Maintains appropriate written and oral communication on a timely basis, completing documentation within 24 hours of activity, and returning non-urgent calls within 48 hours
- Conducts educational and training activities that promote appropriate, safe, effective patient care.
- Participates in activities and education to maintain and advance competency.
- Participates in CCA quality improvement efforts.
- Assists CCA management and leadership with the development, refinement and enhancement of clinical programs, initiatives, processes, policies, workflows, and projects.
Participates in committees and workgroups that promote clinical excellence and help to advance CCAs mission and business objectives.
Maintains confidentiality of patient information.
Complies with organization's policy and procedures.
Advocates for patients in a culturally competent manner.
Seeks maximum patient and family participation to promote independence.
- Predominantly in the community. Must be willing and able to travel to patient's homes in addition to working in an office environment occasionally.
- Reliable transportation required.
- Valid driver's license with no restrictions. Ability to be active and mobile across Massachusetts (85% travel required).
What We're Looking For:
- Minimum Education Required - Master's Degree in Social Work, Mental Health Counseling or Psychology
- Licensure with the Commonwealth of Massachusetts as a LCSW, LICSW, LMHC, Psy-D, or PhD in good standing.
- Licensure with the Commonwealth of Massachusetts as a LCSW, LICSW, LMHC, Psy-D, or PhD in good standing.
- Minimum Years' Experience Required - 5+ years meaningful clinical experience in care management.
- Crisis and substance use experience, including telephonic.
- Past experience caring for patients/members with complex medical, behavioral health, and social needs in a community setting is strongly preferred.
- Demonstrates understanding of the Model of Care.
- Demonstrates understanding of when a BH Assessment and MDS/BH support is needed.
- Demonstrates understanding of LTSS.
- Demonstrates ability to use SBAR Communication Tool.
- Ability to lead a family/team meeting for the purposes of discharge planning.
- Demonstrates knowledge and ability to use depression screening/ assessment tools (e.g., PHQ 2, PHQ 9)
- Demonstrates understanding of Referral to Specialist.
- Ability to conduct and document a Pain Assessment, Mental Health, SUD, Crisis and Cognitive Assessments.
- Willing to learn and utilize telehealth technologies (video, chat, etc.), when appropriate, for a variety of clinical care and care management services.
- English
- Bilingual in Spanish preferred
Equipment Utilized
- Standard office equipment
- Experience with electronic medical record strongly preferred (EPIC and eCW a plus)
Physical Requirements
- The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.
- Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
- While performing the duties of this job, the employee is regularly required to stand; use hands to finger, handle, or feel; reach with hands and arms; and talk or hear.
- The employee is occasionally required to walk; sit; and stoop, kneel, crouch, or crawl
- The employee must frequently lift and/or move up to 10 pounds and occasionally lift and/or move more than 100 pounds.
- Specific vision abilities required by this job include close vision, distance vision, and ability to adjust focus.
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