Registered Nurse - Transition of Care Manager
The Transition of Care (TOC) Manager will see Behavioral Health Community Partner (BH CP) Assigned and Engaged Enrollees at inpatient facilities and Emergency Departments (EDs) for the purpose of engaging Enrollees to complete BH CP Participation Forms, Consent Forms and comprehensive assessments. The TOC Manager will further ensure warm hand-offs to BH CP staff for the purpose of delivering ongoing care management services and may maintain a caseload of Enrollees following discharge from inpatient facilities where Brien Center Enrollees utilize services. The TOC Manager may assist with developing, and possibly implementing, Person-Centered Treatment Plans (PCTPs) in collaboration with the BH CP Teams.
The TOC Manager will be responsible for initial outreach and engagement of Enrollees who utilize facility-based services and will plan and implement interventions related to TOCs. This position supports Care Coordinators working with medically and psychologically or duel diagnosed complex individuals and their families.
Essential Job Functions
- Engage Brien Center BH CP Assigned and Engaged Enrollees in the inpatient, ED and crisis settings to deliver BH CP servicesImmediately review and prioritize a list of hospitalized BH CP Assigned and Engaged Enrollees on a daily basis; meet with Enrollees immediately upon identification of all individuals who are utilizing facility-based services.
- Delegate support functions to additional BH CP staff (e.g. Care Coordinators), to meet with 100% of Enrollees who utilize facility-based services on a daily basis. Follow-up with Enrollees who are not available at an initial contact on the same day of such contact. Track and follow-up with Enrollees who have left the facility on the day of discharge either directly, or in combination with BH CP team members.
- Complete all required documentation in a timely manner
- Consult with Brien Center BH CP medical, behavioral and other staff, as needed, to meet the person-centered needs of Brien Center BH CP Enrollees.
- Convene Interdisciplinary Care Team (ICT) meetings, as needed, for the purpose of planning TOCs. Collaborate with BH CP staff to plan and execute such meetings and transitions.
- Collaborate with Berkshire Health System care management and discharge planning staff, providers, community-based Social Service Providers, BH CP team members, Crisis Teams, and other community-based supports to ensure the delivery of whole-person BH CP care management services including, but not limited to, effective transitions of care for Enrollees who utilize inpatient, ED, crisis and other facility-based health care services
- Attend and actively participate in TOC and discharge planning meetings and the development of interventions at the earliest point in the Enrollee’s facility -based care
- Establish positive relationships with community organizations and services for the purpose of initiating and implementing meaningful TOCs.
- Collaborate with Brien Center BH CP staff to review and augment Assessments and PCTPs to include appropriate information and goals for individuals who experience facility-based TOCs.
- Provide temporary assistance with transportation to needed TOC-related appointments in the absence of Care Coordinator or other options.
- Manage Care Coordinator follow-up of all TOC interventions in collaboration with BH CP staff.
- Meet reporting requirements to inform the ACO of TOC activities.
- Participate in supervision as required
- Participate in all trainings as required
- Represent agency in a professional manner in all community contacts
- Maintain ethical and professional standards
- Demonstrate a commitment to the Agency’s mission and community mental health principles
- Driver’s license checks (RMV)
- Criminal Offender Record Information Check (CORI)
- Meet all credentialing requirements
- Registered Nurse with current licensure in Massachusetts required
- Minimum of 5 years experience in nursing or healthcare within the last 5 years
- Minimum of 5 years experience of working with adults with serious and persistent mental illness and substance use disorders
- Minimum of 5 years of experience with local resources, navigating health, behavioral health, and substance use treatment systems
- Proficient computer skills and knowledge of EHR systems
- Excellent collaboration and relationship building skills
- Excellent written and verbal communication skills
- The ability to pay close attention to detail
- Excellent communication, documentation, time management, and organizational skills
- Flexible and able to adapt to frequently changing standards and priorities
- Works in community setting and office
- Works off-site and travels to the Brien Center as needed
Physical Conditions and Requirements
- Most functions are computerized
- Lifting might be required
- Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of their positions