CIC (Community) BH Clinician

Position Summary:

Commonwealth Care Alliance's (CCA) Community Intensive Care (CIC) programing is responsible for providing care delivery and care management to a specific panel of high risk and complex people. This panel of patients incorporates the care of individuals with significant medical, behavioral, and social complexities that require intensive care management and care delivery.

Within the CIC Program, The Senior Clinician, Behavioral Health (SBHC) serves as a leader for behavioral health care delivery and care coordination for the most complex medical and behavioral health patients. The SBHC functions within and is an integral part of a highly skilled interprofessional team model. The SBHC ensures that a defined panel of patients receives the highest quality community-based within the context of a patient centric individualized plan of care. The SBHC uses evidence-based care approaches, clinical skills, education, and training to influence the clinical outcomes of assigned patients by impacting acute care utilization, ensuring optimal treatment for behavioral health needs, and closing quality gaps.

Additionally, the SBHC interfaces closely with the patient's external care team members including the PCPs, care providers, and specialists, among others to maintain collaboration with the patient's entire healthcare team. The SBHC utilizes all technological modalities and conducts visits within the patient's home, community and at area facilities to ensure connection and optimize care. The SBHC will interface with patients during transitional space to promote hospital avoidance and readmission reduction. Additionally, the SBHC will provide ongoing bridge therapy, urgent visits, crisis intervention, and promote care and wellness strategies. The SBHC engages in visits at regularly scheduled intervals to conduct regular behavioral health assessments to ensure the patient's Plan of Care is comprehensive and addresses significant behavioral needs.

This position requires in-person visits to patients in their homes and the community across various locations.

This position reports to the CIC BH Clinical Manager.

Supervision Exercised:

• No, this position does not have direct reports.
  

Essential Duties & Responsibilities:

The primary function of the CIC SBHC role is delivering behavioral health care to CCA's most complex patients, providing care management and care coordination support, and collaborating with external providers with the goal of delivering comprehensive care.

Essential Duties include - best in class patient care; clear, concise, and effective communication and documentation; and interdisciplinary team collaboration with a variety of stakeholders internally and externally

Patient Care:

The SBHC is expected to perform longitudinal routine and urgent, relationship-based, behavioral health care support for and attributed patient panel including (but not limited to):

• Conducting episodic urgent visits to ensure that patients are given timely and appropriate behavioral health support and care to avoid emergency room or hospitalization.
• Timely Psychiatric post hospital discharge with focus on hospitalization and utilization reduction
• Facilitating and/or delivering preventative care and behavioral health assessments.
• Long Term support for patients with the most significant behavioral health needs and severe persistent mental illness (SPMI)
• Occasional long-term bridge therapy for members awaiting network referral for Behavioral Health Provider
• Support in identifying, supporting, and optimizing substance use disorder (SUD) treatment by working with the interprofessional care team and conducting referrals for addiction treatment.
• Conduct behavioral health assessments, provide diagnosis as appropriate for psychiatric conditions, identify treatment plans, conduct follow up visits for inpatient psychiatric hospitalizations, perform crisis follow ups, and conduct consultations for complex cases.
• Conduct patient engagement via telehealth technologies (video, chat, etc.) for appropriate clinical care and care management services.
• Conducting multiple patient visits within each business day balancing routine, scheduled encounters with episodic or urgent visits to maintain expected productivity.
• 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.
• 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.
• Performs crisis assessment and referrals to CSU and inpatient facilities as needed.
• Identifies SUD needs and makes appropriate referrals for treatment and follow up.
• Facilitates family meetings and participates in discharge planning meetings.
• Provides patient education on substance use disorder and mental health concerns.

Documentation/Accountability

• Document all visits with focus on clear, comprehensive, and concise charting. Must be able to document in English.
• Identify, document, and execute a patient centric plan of care. Ability to communicate and delegate care plans as appropriate utilizing multiple modalities of communication
• Completion of all tasks within appropriate timelines as outlines in Scopes of Practice and CCA Guidelines
• Comply with organizational policies and procedures.
• Maintain patient and employee confidentiality
• Participate in evaluation of own performance and progress
• Identify and initiate a plan to resolve areas of opportunity to meet Key Performance Indicators (KPI's).

Interdisciplinary Team Collaboration

• Serve as a clinical mentor and leader for behavioral health care
• Conduct on-going and effective collaboration and communication with external providers, including but not limited to Primary Care staff, specialty services, LTSS coordinators, Aging Service Access Points (ASAPs), visiting nurse services, care attendants, patient designated contacts, and next of kin.
• Conduct on-going and effective collaboration and communication with interdisciplinary team including but not limited to, Health Plan Care Team members, Community Advanced Practice Clinician, Community Licensed Practical Nurses, Community Health Workers. Provides recommendations to Care Team as to best strategy in managing patients based on psychological drivers for maladaptive behaviors.
• Maintains a connection to community services and on-going care coordination with community providers
• Researches and provides community psych resources.
• Participates in CCA quality improvement efforts
• Participates in regular Interprofessional Care Team meetings and Team Case Review.
• Participates in Risk Management meetings as needed.
• Conducts educational and training activities that promote appropriate, safe, effective patient care.
• Assists CCA management and leadership with the development, refinement and enhancement of clinical programs, initiatives, processes, policies, workflows, and projects.

Other duties as assigned.

Working Conditions:

• This position requires in-person visits to patients in their homes and will support patients across various locations.
• This position requires travel to CCA sites and offices per required need for various team meetings.
• Valid driver's license with no restrictions. Ability to be active and mobile across assigned catchment area.
• COVID-19 vaccination is required
• Compliance with all Community Clinician Occupational Health Requirements.

Other:

Equipment Utilized

• Standard office equipment

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.
• Must be able to come to the local CCA office
• May require meetings across the state.

Required Education (must have):

• Master's Degree in Social Work, Mental Health Counseling or Psychology

Desired Education (nice to have):

Required Licensing (must have):

• State licensure as a LCSW, LICSW, or LMHC in good standing.
• MassHealth enrollment required if holds a LICSW

Desired Licensing (nice to have):

MA Health Enrollment (required if licensed in Massachusetts):

• Yes, this is required if the incumbent is licensed in Massachusetts.
  

Required Experience (must have):

• 5+ years meaningful clinical care and care management experience with patients with complex medical, behavioral health, and social needs; preferred experience in community settings. in care management.
• Crisis and substance use experience, including telephonic.

Desired Experience (nice to have):

• Experience with electronic medical record strongly preferred (EPIC and eCW a plus)
• Experience with Medicaid or Medicare programming and insurance products (i.e. ACO, MCO, PACE or SCO)

Required Knowledge, Skills & Abilities (must have):

• 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.
• Proven skills, knowledge base, and judgement necessary for independent clinical decision making in alignment with clinical licensure, ability to problem solve.
• Strong and effective communication skills, written, verbal, and via electronic modalities
• Effective teaching skills
• Mediation and conflict resolution skills
• Effective organizational and time management skills
• Ability to advocate for a complex patient population in a culturally competent manner

Required Language (must have):

• English

Desired Knowledge, Skills, Abilities & Language (nice to have):

• Willing to learn and utilize telehealth technologies (video, chat, etc.), when appropriate, for a variety of clinical care and care management services.
• Demonstrated ability to utilize and toggle through multiple EHR platforms
• Bilingual or multi-lingual