CPLC Centro Esperanza offers specialized services for SMI populations focusing on case management and psychiatric services.

PRIMARY FUNCTIONS

As a clinical team member, assists with completing assessments and service plans and implements requested services to members according to their individualized service plan (ISP). Communicates and documents members' progress toward their recovery. Coordinates and monitors rehabilitation-related services for members with serious mental illness.

Works with a maximum of 20 members, who the clinical team identifies, utilizing the criteria outlined in implementing the IPRPT Boston University Model. Works with assigned RSA Vocational Rehabilitation Counselor, community rehabilitation program providers, and other parties involved to assist members in increasing or maintaining involvement in learning, working, living, and social activities.

JOB RESPONSIBILITIES AND COMPETENCIES  

Works collaboratively with the clinical team to engage, educate, communicate, and coordinate care with a member, their family, behavioral health, medical and dental providers, community resources, and others to implement all services prescribed in the individualized service plan.

Utilize the Boston University Intensive Psychiatric Rehabilitation Program Team Approach (IPRPT) to assess members’ needs, including living, learning, working, and social leisure goals, and assist members with reaching their desired role achievement in any or all of these environments. Provides supportive services including, but not limited to, the following: 

•         Assistance in maintaining, monitoring, and modifying covered behavioral health services; 

•         Brief telephone or face-to-face interactions with a person, family, or other involved parties to maintain or enhance a person’s functioning; 

•         Assistance in finding necessary resources other than covered services to meet basic needs; 

•         Serves as a point of contact and ensures ongoing collaboration, including the communication of appropriate clinical information with other involved parties as appropriate and coordination of care with a person’s family, behavioral and general medical and dental health care providers, community resources, and other involved supports including educational, social, judicial, community and other State agencies; 

•         Ensures the provision of all covered services identified on the service plan; referrals to community resources as appropriate and coordination of care activities related to continuity of care between levels of care and across multiple providers, services, and supports; 

•         Participates in staffing, case conferences, or other meetings with or without the person or his/her family participating; 

•         Provides transportation to consumers as appropriate and determined by the clinical team;

•         Assists the clinical team in completing the service plan, including providing recommendations about the member’s educational, vocational, social, and community integration goals. 

•         Collaborates with the person and his/her family or significant others to implement an effective service plan, explaining the available clinical options to the team, including the advantages and disadvantages of each option.

•         Maintains the person’s comprehensive clinical record, including documentation of activities performed in the service delivery process (e.g., assessments, provision of services, coordination of care, discharge planning).

•         Provides continuous evaluation of the effectiveness of treatment through the ongoing assessment of the person and input from the person and relevant others, resulting in modification to the service plan as necessary.

•         Pursues best practice outcomes for persons with mental illness, including continuing education, employment, independent housing, and community tenure.

•         Educates team members as the subject matter expert regarding rehabilitation and vocationally related issues and provides ongoing technical training and support to the team as requested or indicated, including updates on available community resources, how to utilize the services of the co-located RSA/VR counselor or co-located vocational providers.

•         Develops relationships with community employers, providers, or other organizations to foster increased employment and meaningful community activity opportunities for members.

•         Provides individual and group guidance in identified areas of need as determined by assessments including, but not limited to, the IPRPT model utilizing the Readiness Assessment, Functional Assessment, Skill Development Modules, DB 101, and tools.

•         Other duties as assigned.

NOT part of an ACT Team