POSITION SUMMARY

The Clinical Care Manager (Care Coordinator) is responsible for delivering, integrating, and coordinating supportive services for assigned individuals at the 801 East Men’s Shelter, which is funded by a grant agreement with the District’s Department of Human Services (DHS). Focusing on the intersection of healthcare and social/behavioral/housing supports, the Care Coordinator works with multiple systems of care, both inside the shelter (e.g., between Day Center, Housing Focused Case Management, Employment Services, Low Barrier Shelter, Work bed, Senior/Frailty, Recuperative Care, and Health Clinic) and with outside providers (e.g., medical specialists, hospitals, behavioral health providers, etc.). The goal is facilitation of integrated, whole-person care. The Assistant Program Director fields requests and referrals from staff working across the other on-site programs and supports the Care Coordinator with developing a rotating caseload of ~25-30 guests with high priority presenting situations.

Work Schedule: Monday - Friday from 1PM - 9:30PM.

KEY RESPONSIBILITIES

DIRECT SERVICES PROVISION

• Engage assigned guests with Evidence Based Practices (EBP) to build trust/ develop rapport (e.g., Motivational Interviewing, Stagewise Case Management, Trauma-Informed Care, etc.)
• Support guests with identifying strengths and opportunities.
• Provide In-Reach services at the shelter, recognizing that some participants will prefer to avoid service providers. Provide individual and group services
• Assist Shelter Operator team with Orientation, Screening, and Bed Placement with individuals staying in the shelter
• Track timely delivery of service according to the Critical Time Intervention EBP, ensuring a regular and complete review of each guest’s progress toward integrated care.
• Conduct group workshops on a range of topics related to whole-person, integrated care in the Day Service Center.

CARE COORDINATION

• Ensure coordination of integrated health services with providers and vendors in the building (e.g., Day Center, Housing Focused Case Management, Employment Services, Respite Program, and Health Clinic)
• Coordinate with on-site medical staff to ensure guests have the care/supports needed.
• Consult/team with Benefits Specialist, Housing Navigator, Housing Focused Case Manager, Peers, Employment Specialist, Respite Staff, and Health Clinic to ensure guests are receiving necessary and integrated services.
• Serve as general liaison to external providers including PSH, RRH, health/behavioral health providers, and/or employment and training providers, focusing on the integration of person-centered healthcare.
• Connect guests with needed community-based supports by scheduling appointments, participating in three-way check-ins (as appropriate and invited by the guest), and ensuring the guest has the resources needed (e.g., transportation tokens) to follow through on appointments and other commitments.
• Participate as assigned in community-based service access and coordination meetings.
• Coordinate with hospital staff and other healthcare providers in the community to receive and send referrals.
• Oversee placements into Medical Respite beds, orient guests to their anticipated length of stay and care plan.
• Work closely with the Health Clinic and Medical Respite to ensure timely sharing of information needed for health maintenance and treatment planning
• Coordinate with the onsite food vendor for meal delivery for guests unable to leave the Medical Respite floor.
• Work with guests on discharge plans to ensure safe and appropriate placement following their stay in the Medical Respite Program, including supporting connections to appropriate Long-Term Care options.

DOCUMENTATION & CARE REVIEW

• Participate in analysis of data-driven and qualitative feedback with the goal of improving service and outcomes.
• Assist in the development of daily, weekly, monthly, and Quarterly reports for DHS and be familiar with the reporting functions off HMIS
• Enter accurate, complete, timely, and compliant documentation in required systems e.g., HMIS and other applicable databases.
• Document in HMIS all guest meetings, collateral contacts, referrals, missed meetings, and any other relevant information pertaining to the guest's progress towards integrated care.
• Prepare accurate and compassionate Notices to participants for review by supervisory staff, e.g., Exit, Termination, Extension Notices.
• Participate in obtaining guest/customer/stakeholder input/feedback and routinely review and incorporate information obtained via that process.
• Identify and manage risk posed during the delivery of Integrated Care and Respite Services. Understand, and report risk assessments to the assigned supervisor.
• Participate in review of guest progress during supervision, huddles, team meetings and other evaluation sessions. Work with supervisor to effectuate needed changes.
• Provide high quality, efficient services that are consistent with the goals and mission of Community Connections and DHS.

In addition to role responsibilities, each staff member of Community Connections has the following responsibilities as a part of their employment:

• Models and reinforces Community Connections mission to provide behavioral health, residential services, and primary health care coordination for marginalized and disenfranchised women, men, youth, and children living in the District of Columbia, many of whom are coping with challenges including mental illness, addiction, and the aftermath of trauma and abuse.
• Models and reinforces Community Connections values of quality, innovation, respect, equity, and integrity daily.
• Reinforces Community Connection’s commitment to diversity, equity, and inclusion.
• Protects the privacy of our consumer’s protected health information by maintaining compliance with HIPAA and other relevant CC related IT security regulations.
• Completes and stays current on role specific and organizational wide training.
• Performs other duties as assigned on an as-needed basis.

DESIRED KNOWLEDGE/SKILLS/ABILITIES:

• Bachelor’s degree in related health, human services, social services, nursing, or equivalent required; Master’s degree in Social Work, Counseling, Public Health, or equivalent preferred
• Minimum 4 years’ professional experience working in a related health, human service, or social services field required
• Experience working in homeless services and/or supportive housing required
• Experience with the “Housing First” model preferred (And experiencing with Critical Time Intervention, Motivational Interviewing, and Stagewise Case Management also a plus)
• Experience working with adults experiencing mental health, substance use, and or trauma preferred
• Experience with non-profit organizations a plus
• Demonstrated ability to communicate effectively
• Effective interpersonal skills required, along with a high level of discretion and a manner of confidentiality
• Proficiency in Microsoft Office Suite software (Word, Excel, Outlook, PowerPoint, etc.)
• Proficiency utilizing electronic health record systems, or guest data/management information systems. Experience with Homeless Management Information System (HMIS) a plus
• Organization skills and ability to pay attention to detail a plus
• Service-oriented, diplomatic, and energetic
• Ability to work proactively and independently in a fast-paced setting
• Must think critically and ethically about service delivery
• Ability to communicate effectively in person, virtually, and by phone with guest population, network members and collaborative service partners
• Ability to read, analyze, and interpret documents

POSITION TYPE/EXPECTED HOURS OF WORK

• May need to work non-traditional work hours such as weekends, evenings, observed holidays, and nights.
• This is an essential or critical position which will require reporting to a physical work location or making visits to consumers in the community as defined by the business needs of Community Connections, Inc