Health Home Plus (HH+) Care Coordinator - Full-Time

Transitional Services for New York, Inc., not-for profit, is a comprehensive, community-based mental health organization located in New York City. We provide a continuum of rehabilitative services to enrich the lives of those recovering from mental illness and facilitate their transition to increased levels of independence. Transitional Services for New York, Inc. envisions broadening its rehabilitative services and becoming a regional social service provider. Transitional Services for New York Staff will deliver effective programs with compassion, integrity, and professionalism. We expect all staff to put our clients’ needs first while respecting ourselves and each other as we provide hope to those who participate in our programs.

TSINY is seeking Health Home Plus Care Coordinator for one of its Outpatient Programs in Jamaica (Queens), NY.

Annually Salary: $45,000 annually, $24.72 Per Hour, Full-Time

Position Summary

The Health Home Care Coordinator functions as a member of an interdisciplinary team to provide intensive care management services to individuals identified as Adult Home (AH) class members under the Stipulation and Order of Settlement, United States vs. State of New York... and who are interested in transitioning into the community.

Essential Functions

• Evaluate the class member's interest in transitioning from the adult home into the community.
• Educate the class member on the benefits of transitioning into the community.
• Refer the class member to the Housing Contractor for in-reach as soon as they express an interest in transitioning.
• If the class member does not want to transition, enroll the class member in a Health Home, have them sign the Health Home Consent Form, and refer to another worker.
• If the class member wants to transition, enroll the class member in a Health Home and have them sign the Health Home Consent Form.
• Complete the Discharge Planning Tool (DTP) for class members scheduled to transition into the community and forward the completed DTP to the Community Transition Coordinator (CDC) at least two business days prior to the pre-transition call of the class member.
• Participate in all pre and post transition calls
• Provide at least four (4) face-to-face contacts with the class member monthly.
• Conduct at least monthly phone and/or face-to-face contact with class members Housing Contractor Participate in weekly telephonic calls with NYSDOH to share information about the class member. Review the class member's need for securing identification and benefits and assist the class member or directly undertake any necessary applications/renewal processes.
• Assist in the movement process from the adult home into the community.
• Following transition out of the adult home, work with the class member and the multi-disciplinary team to provide support consistent with the care plan and to foster ongoing skill-building and independence.
• Re-assess the class member's needs five months after transition to determine if the class member still requires Adult Home Plus case management services. Graduate the class member from these services if they are no longer needed. Maintain the class member if these services are still needed.
• Continue with weekly contacts until the class member graduates from Adult Home Plus services.
• Document all Health Home Core Services and other services provided.
• Be able to sit or stand as needed, with or without reasonable accommodation.
• Be able to travel independently by public transportation.
• May require walking, primarily on a level surface, for short periods throughout the day, with or without reasonable accommodation.
• Be able to reach above shoulder heights, below the waist or lift as required to file documents or store materials throughout the workday, with or without reasonable accommodation.
• During a declared disaster, assume and adhere to assigned Job Action role(s) consistent with Disaster Preparedness Plan.
• Perform other related duties as required.

Experience/Education/Skills/Abilities

a. Education

A bachelor's degree in one of the following fields (social work, psychology, nursing, rehabilitation, education, occupational therapy, physical therapy, recreation or recreation therapy, counseling, community mental health, child and family studies, sociology, speech and hearing, or other human services fields), or ii. A NYS teacher's certification for which a bachelor's degree is required; or iii. NYS licensure and registration as a Registered Nurse and a bachelor's degree; or iv. A Bachelor's level education or higher in any field and five years of experience working directly with person with behavioral health diagnosis; or v. A Credentialed Alcoholism and Substance Abuse Counselor (CASAC)

b. Experience:

• Two years of experience in: Providing direct services to persons with Serious Mental Illness, developmental disabilities or substance use disorders; or

Linking individuals with Serious Mental Illness, developmental disabilities or substance use disorders to a board range of services essential to successful living in a community setting (e.g. medical, psychiatric, social, educational, legal, housing and/or financial services).

• A master's degree is one of the qualifying fields may be substituted for one year of experience.