Why This Role is Important to Us:
The Community Behavioral Health Specialist (BHS) ensures that a defined panel of dually eligible individuals receive the highest quality, behavioral health care within the context of a member centric individualized plan of care. The Community BHS has the opportunity to use evidence, clinical skills, education, and training to influence the clinical outcomes of CCA’s members by impacting acute psychiatric hospitalizations, optimal treatment for severe, 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 members, the Community Behavioral Health Specialist will engage in regular assessments, visits at regularly scheduled intervals, and conduct acute visits to ensure that members’ Plan of Care is fully comprehensive and addresses significant medical, behavioral, and social needs.
The Community Behavioral Health Specialist will identify gaps in member’s care and unmet needs. The Community BHS will coordinate with the Telephonic Care Partner along with the PCP (Primary Care Provider), Community BH, social supports and CCA’s interprofessional clinical care team to identify areas of opportunity, as well as defined resources, and will work in coordination with the team to implement the care plan. The Community Behavioral Health Specialist will engage in direct delivery of Behavioral Health Care for identified members who are in need of bridge therapy while awaiting a referral to a network Behavioral Health provider. There is also opportunity for a Community BH Specialist to hold a defined panel of members with Severe Persistent Mental Illness, and will provide long term support for those with the most significant behavioral health needs. The Community BH specialist will have an ability to engage with members with identified or rising risk of Substance Use Disorder, and work with the interprofessional care team to ensure that members are appropriately referred for addiction treatment. The Community BHS is a member of the care team that provides behavioral health assessments, diagnosis, psych hospital/ Crisis DC follow-up as well as consultation, education, and support to members and other team clinicians regarding behavioral health/ substance abuse treatment and management.The BH Community Role reports to a BH Manager or BH Director.The Community BHS also provides input to members’ Telephonic Care Partner on key care management/ care coordination decisions, including the adjustment of the member-centered care plan and identification of the need for services and/or equipment.
What You'll Be Doing:
Performs episodic urgent visits to ensure that members 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 members according the guidelines deemed appropriate by CCA Clinical Leadership. Guidelines may vary based on the individual make-up of the member and is based on age, co morbidities etc.
Identifies and initiates a plan to resolve areas of opportunity to meet quality metrics.
Review a checklist of member needs, prior to each visit, to assist member with scheduling ACA and MDS visits
Review members’ quality gaps prior to every visit and collaborate with care partner to close these gaps
Meets BH HEDIS with-hold metrics following strict follow-up and documentation guidelines
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 CCA Care Partner and community-based PCPs/ Specialists and community BH providers as needed
Documents all activities and results using both the Electronic Medical Record and Care Management Platform, in an effective manner while strictly adhering to CCA policies and procedures
Adjusts the member centered plan of care as necessary based on a significant change in condition. A change in condition is an event (hospitalization, substance use episode, Crisis etc. ) which results in either a short or long term change in need (examples include adding in Diversionary Srvs, Peer or Recovery Support)
Ensures that the plan of care is implemented in a timely manner.
Works closely with Telephonic care Partner to ensure that Care Plan is accurate, up to date and reflect members BH needs
Provides behavioral health support and consultation to clinical team disciplines and other teams as needed
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 members mental health and psycho-social needs
Participates in Capacity Assessments
Performs short-term bridge therapy to members
Maintains a connection to community services and on-going care coordination with community providers
Assists community APCs with Risk Adjustment Diagnosis Coding during ACAs
Assists in MDS assessments if member meets BH criteria for MDS assessment support
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
What We're Looking For:
Minimum Education Required - Master's Degree in Social Work, Mental Health Counseling or Psychology
Preferred Educational Experience Licensure with the Commonwealth of Massachusetts as a LCSW, LICSW, LMHC, Psy-D, or PhD in good standing.
Minimum Experience - Five+ years meaningful clinical experience in care management
Past experience caring for patients/members with complex medical, behavioral health, and social needs in a community setting is strongly preferred.
Crisis and substance use experience, including telephonic.
Ability to conduct and document a Pain Assessment, Mental Health, SUD, Crisis and Cognitive Assessments
Ability to use SBAR Communication
Ability to utilize an Electronic Medical Record
Ability to use on-line training platforms
Demonstrated understanding of the Model of Care
Demonstrated understanding of the benefits of CCA’s product lines; One Care and SCO
Ability to review welcome packets and obtain consent forms and attach them to EMR
Demonstrated understanding of when a BH Assessment and MDS/BH support is needed
Ability to complete and update a Care Plan that meets CCA requirements
Demonstrated understanding of LTSS
Demonstrated understanding of how to use CDSTs when ordering services
Ability to complete and lock all required telephone encounters within 48 hours
Ability to lead a family/team meeting for the purposes of discharge planning
Demonstrated knowledge and ability to use depression screening/ assessment tools (e.g., PHQ 2, PHQ 9)
Demonstrated understanding of Referral to Specialists
Ability to initiate referrals and authorize services within appropriate time frames Preferred:
Demonstrated understanding of, and can apply, member stratification
Demonstrated understanding of how Minimum Data Set (MDS) supports stratification