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|Department:||Community Based Support|
Provides Service Coordination carefully calibrated to the level of need of the individual and or family being served. The Service Coordinator will be responsible for the performance of the General Service Coordination duties as well as the specific duties as assigned to each level of service.
The primary function of the Service Coordination is to provide the person with serious mental health issues with professional assessment, service planning, service coordination, referral, and re-evaluation services required for a safe and healthy community life which is manifested through stability in relationships, housing and employment or meaningful activity. The development of enduring relationships with those served is critical, with persistent outreach, being the central contact point in the system, coordinating care and assisting the person in their recovery process. This is done in accordance with Pressley Ridge’s vision, mission and values, and emerging mental health Recovery Principles. This position provides an essential recovery orientation.
Essential Roles and Responsibilities
A. General Service Coordination
The Service Coordinator provides professional coordination of mental health services according to the individual’s level of need. The incumbent works as a member of a treatment/service team, often taking the lead role, and using considerable discretion and independent judgment in order to promote individuals’ mental health recovery. The Mental Health Service Coordinator serves as a key member of the treatment/service team, assuring often complex services produce positive outcomes.
1. Engagement/Developing Enduring Relationships
Develops relationships with the individual, his/her family and other important people in his/her life as identified and with consent of the individual served. This engagement will be persistent and will result in an enduring relationship. The persistence is evident in frequent outreach and genuine concern over a lengthy period of time.
Assesses individual and family strengths and needs in a collaborative method through individual and/or collateral interviews and reviews of social and clinical information provided by other entities. The development of an assessment is based on an understanding and trusting relationship, that needs and strengths vary over time and are evaluated in every contact (face to face and phone). This ongoing assessment will be augmented by consultation with other members of the treatment team and any others with relevant knowledge. Ideally the Service Coordinator’s information gleaned from the consumer will not be the only source of information for the assessment.
3. Service Planning
In close collaboration with the consumer, family members and other service providers, promotes service planning efforts which result in developing, documenting and implementing a comprehensive service plan driven by the individual utilizing all the agreed upon strengths and needs. The services provided then follow the conjointly developed service plan pursuing all of the objectives developed. As strengths and needs change, the service coordinator with the consumer, alter the service plan to meet the changing needs and utilize the new strengths. Plans will be formally reviewed every three months, according to accreditation and state regulations.
Evaluates all services received by individuals who are served by the Service Coordination program. Reviews cases, meets with individuals’ families, members of the treatment team, agency directors, advocates, attorneys, school personnel and attends staffing in or out of the office. Advocacy or problem solving is provided when the individuals are not receiving the service described in the service plan unless they no longer want that service.
5. Resource Expert
Investigates new resources and communicates with directors of prospective resources as a liaison on behalf of the individual being served. Maintains an up-to-date catalog of available community resources, including location, eligibility requirements and program alternatives.
Convenes and facilitates interdisciplinary service planning meetings or other related team meetings to ensure appropriateness and responsiveness of services in relation to individual and/or family needs. Whenever possible, the individual, family and others requested by the individual will be present in service planning meetings.
7. Linkage To Natural Supports
Ensures individuals being served needs are met through the utilization of natural supports (family, friends), community and generic services and specialized services (MH/MR, Supported Employment, OVR, D&A). Assists individual and family to identify, link, access and coordinate such resources. The involvement of families is highly desirable and will be vary based on the consumer’s wishes, the age of the consumer and other unique factors.
8. Cultural Competence
Provides culturally competent services with consideration for the individual’s racial, religious, sex, sexual orientation, age and ethnic background and identification.
Advocates for and with the individual being served to ensure responsiveness from natural, community generic and specialized services/supports. Advocacy includes providing information, removing barriers, creating options and resolving problems.
Attends training programs as provided through the State, County and Agency to assure that the incumbent is up to date on new approaches, best practices and recovery oriented services.
a. Maintains an accurate and timely record of Service Coordination activity. Records individuals being served and collateral contacts. Updates forms as needed. Reviews charts for compliance with regulations. Documentation will use the individual’s language and describe his/her perspective. Adheres to regulations for each level of Service Coordination in this area.
b. Maintains the statistical requirements for each level of Service Coordination service. This will include agency, county, state and managed care requirements.
c. Completes Service Documentation forms, Service Coordination Outcomes and other program material within designated time frames.
12. Blended Level Of Service Coordination Level 1
Ensures face-to-face and/or phone contact to the individual being served based on the individuals needs but at the very minimum at least two (2) times per month to assist individuals to build on strengths and achieve goals.
13. Blended Level Of Service Coordination Level 2
Ensures contact with the individual being served (or the parents if the individual is a child or adolescent) based on the individuals needs but at the very least once a month. Face-to-face contact with an adult being served will be made every two months. Face-to-face contact with a child or adolescent being served will be made every month.
Provide a full range of Service Coordination services to a designated caseload maximum
of 25 for children.
15. SPA Expectations
Provide these affirmative Single Point of Accountability (SPA) responsibilities:
a. Be the “go-to” resource for the person served, his/her family and the system of care.
b. Assure that there are effective “safety net” resources for the persons served.
c. Clearly communicate to the person what they can expect from the system and what the system will expect of them.
d. Assure there is periodic assessment & cross-system planning to meet the needs while utilizing their strengths.
e. Prepare for, convene/facilitate service planning meetings and provide follow-up after meetings.
f. Assure there is cross system coordination of services and that services are being provided.
g. Develop relationships that endure with persistent outreach even when there is reluctance to receive services.
h. Assist the person served in developing and using natural supports.
i. Be a persistent advocate for those served and give feedback on systemic problems.
j. Provide a consistent positive outlook which encourages recovery and full inclusion in the community.
Utilizes at least 75% of available time in service to individuals being served.
1. Knowledge of position responsibilities including state mandates and county expectations and the guidelines & regulations for all levels of Service coordination (Levels 1&2).
2. Knowledge of the principles used in providing service coordination services.
a. Single Point of Accountabilities
b. Recovery Principles
c. Community Support Principles
d. CASSP and High Fidelity Principles
e. Interviewing techniques
3. Ability to identify the strengths and needs of consumers and/or families and to gain their confidence and cooperation.
4. Ability to pass Child Assessment of Needs and Strengths Certification (CANS) and complete the CANS.
5. Ability to evaluate individuals, their service needs and current utilization of services
a. Individual, current circumstances
b. Mental Status Exam
c. Diagnosis – knows broad diagnostic categories
d. Dual diagnosis (mental illness/substance use or addiction)
e. Co-morbidity of medical conditions
f. Medication management
6. Knowledge on service planning
a. Service planning principles
b. Process of developing a collaborative service plan
c. Development of Crisis Plans
d. Development of WRAP Plans
7. Knowledge and skill in the development and implementation of intervention strategies. Proactive versus reactive interventions.
8. Ability to broker resources including but not limited to recovery focused informal supports and services, formal services/resources, benefits, and entitlement programs.
9. Ability to help individuals find meaningful activity and/or employment and maintain employment.
10. Ability to work with children and adolescents who are in placement, receive services of FSS (Financial Support Services), or who need coordination of care following an inpatient stay.
11. Ability to document services in recovery oriented means including: assessments, progress notes and discharge summaries
12. Ability to use problem resolution skills for advocacy, and education of client’s rights.
13. Ability to convene and facilitate service planning meetings.
14. Knowledge of large systems in Allegheny County (CYF, Probation, MR, Forensics, Aging, Medical).
15. Knowledge of child abuse reporting.
16. Knowledge of systems theory, family systems, family therapy interventions and psycho-education.
17. Ability to identify and manage the symptoms of severe mental illness.
18. Knowledge of medications for managing symptoms of the symptoms of severe mental illness.
19. Knowledge of risk assessment and ability to conduct suicide and violence risk assessments.
20. Ability to manage crises and knowledge of commitment procedures.
21. Knowledge about identifying and managing substance use problems.
a. Knowledge of 12-Step programs, groups, area resources, recovery/prevention/rehabilitation, child and adolescents with disorders, planning and documentation.
b. Ability to identify symptoms, support systems and community resources.
c. Knowledge of treatment needs of MISA population, and resources.
22. Knowledge about identifying and managing co-morbid health problems and promoting wellness.
a. Bachelor’s Degree from an accredited college or university in Social Work, Psychology, Criminal Justice, Pastoral Counseling, Counseling Psychology, Rehabilitation Counseling, Sociology, Education with a certificate in Special Education or Nursing with a Registered Nurse License AND a commitment to attend the post graduate Service Coordination Certificate course within the first year of hire.
Degrees beyond the range listed above require approval of the Sr. Director of Community Based Service Line and may require additional experience from what is described below.
b. All staff hired before September 2010 will complete the Service Coordination Certificate Course before July 2013.
c. Valid State Drivers License and auto insurance. Must have means of reliable transportation. Requires Extensive Travel.
2. Experience: One (1) to Two (2) years of human service experience and working knowledge of human services, paperwork, and PA state regulations for Targeted Case Management.
3. Clearances: State Police/FBI per state regulations; Child Protection
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