Adult Care Transitions ICM

The Adult Care Transitions ICM conducts and schedules assessments, referrals, advocacy and supports, counseling, education of patients and enrollees and care team members assuring the client receives quality intensive services to maintain optimum healthcare needs without barriers. Will adhere to and promote the philosophy and missions of the agency by performing the following duties and responsibilities.

Duties and Responsibilities:

• Provide Intensive Case Management services to hard-to serve individuals. These individuals are considered to be hard to serve in a community, based on level of care; who are pending discharge into the community from hospital acute care, emergency department care, or other institutional settings.
• Collaborate with the Oneida County Department of Social Services. They will conduct assessments, evaluate needs, and establish and maintain referrals for enrollees.
• Provide a safety net to address the needs of individuals who are pending discharge, who have few or no natural supports, to help ensure their safety and successful connection to services and care in the community and prevent future hospitalizations and institutionalizations.
• Upon referral work with client, will plan for a safe and successful discharge for reintegration into the community.
• Participate in regularly scheduled multidisciplinary case conferences scheduled by hospital or institution discharge staff and Oneida County DSS addressing any immediate or ongoing safety needs, and assistance with accessing benefits, services, stable housing, and housing support services.
• Develop both a Safety Plan and Plan of Care based on preliminary information that will identify linkages and services immediately required, based on information received from referral source.
• Responsible for carrying individuals on their caseload for up to 90 days. Will monitor individuals via tele-visit and face to face home visits for a period of 30-90 days to ensure satisfactory implementation of all community based services on the individual's discharge plan and to adjust services.
• Ensure all initial linkages are established and maintained and will advocate for additional services and linkages as appropriate.
• Collaborate with all services providers and establish team communication plan.
• Monitor goals on a continuing basis and ensure that team is communicating.
• Monitor and ensure that care plan is relevant to Intensive Case Management standards.
• Consult with family members and social supports to maintain support consistency.
• Maintain current case documentation and information regarding clients within the required EHR system.
• Work with the client on discharge to a program that fits the needs of the client and is a benefit to their safety and well-being.
• Additional duties may be assigned, on an as needed basis.

Education/Experience:

• Bachelor's degree (B.A.) from an accredited four-year college or university, in Human Services, a mental health field or a related field is preferred.
• At least two years experience in Human Services, primarily Mental Health and Substance Abuse.
• Knowledge of Microsoft Office Suite, Google Suite, and AWARDS.
• Valid NYS Driver's License is required.