Provides direct housing and housing-related services to members assigned to the ACT team, including obtaining and maintaining safe, secure and affordable, permanent housing.
Develops and maintains relationships with county and city housing authorities, as well as other housing stakeholders, and serves as a liaison and point of contact between housing authorities, housing providers, and the health plans housing departments.
Collaborates with the treatment team to assist with mediation and advocacy with landlords on members behalf to develop a workable plan to obtain and maintain housing.
Serves as the expert in housing for all ACT clinical staff.
Performs all service delivery functions associated with ACT team members, including participating in the assessment and service planning processes and identifying the need for further or specialty evaluations.
Works collaboratively with the ACT clinical team to engage, educate, communicate, and coordinate care with each member, their family, and all involved parties to ensure that all services prescribed in the individualized service plan (ISP) are implemented.
Serves as a point of contact and ensures ongoing collaboration, including the communication of appropriate clinical information, with other involved parties as appropriate and coordinates care with a members family, behavioral, medical and dental health care providers, community resources, and other involved supports including educational, social, judicial, community and State agencies.
Collaborates with the member and members family or significant others to implement an effective ISP, explaining available clinical options and the advantages and disadvantages of each option.
Provides continuous evaluation of the effectiveness of treatment through the ongoing assessment of the member and input from the member and relevant others resulting in modification to the ISP as necessary.
Pursues best practice outcomes for members including continuing education, employment, independent housing, and community tenure.
Provides teaching activities and direct services to members to build their skills and enhance their ability to live independently and effectively in the community.
Regularly observes members self administration of medication in their homes or clinic to assist members to understand the purpose of self administration and learn to take their medication(s) independently.
Works with members to develop roles for themselves outside of their mental illness, while focusing on expected outcomes of increased employment, meaningful community activity, independent living status, and social network, as well as decreased substance use/abuse.
Works in collaboration with team members to assure compliance with ACT fidelity measures.
Maintains each members comprehensive medical record, including documentation of activities performed as part of the service delivery process (e.g., assessments, provision of services, coordination of care, discharge planning) and accurately and thoroughly documents all services and activities in the medical record according to policy using approved forms and electronic systems.
Conducts frequent community visits, including but not limited to private homes, Southwest Network sites, provider/treatment/service locations, educational facilities, jail/juvenile facilities, hospitals, and residential treatment/group homes.
Provides or coordinates transportation to members as appropriate and determined by the treatment team utilizing employees personal vehicle.
Practices according to the recovery model and knows and practices engagement skills including motivational interviewing, and assists members to define and achieve their own recovery goals.
Actively participates in staffing, case conferences, or other meetings with or without the member or members family participating.
Follows policies and procedures and adheres to the requirements of the Corporate Compliance Program.
Ensures confidentiality of verbal and written information in accordance with HIPAA standards and Southwest Network policy, and adheres to the legal, ethical and professional guidelines adopted by Southwest Network.
Other duties as assigned.
EDUCATION and/or EXPERIENCE, LICENSURE and CERTIFICATION
Masters or bachelors degree in a field related or similar to behavioral health; a bachelors degree in a non-related field and one year related experience; an associate degree in any field and one year related experience; or a high school diploma or equivalency certificate and three years related experience.
Minimum one year working with seriously mentally ill adults required; previous experience working on an ACT team or equivalent experience preferred.
Minimum one (1) year experience working with behavioral health residential programs and/or housing-related services and resources required.
Must maintain current CPR, First Aid, and Therapeutic Options certifications, as well as self administration of medication certification.
Must have and maintain a valid Arizona drivers license.
Must be at least 21 years of age.
KNOWLEDGE, ABILITY and SKILLS
Requires extensive knowledge and/or previous experience in behavioral health residential programs and housing services and resources, including but not limited to HUD, HQS inspections, public housing programs, and auditing of low income housing programs.
Also requires knowledge of ADA, Fair Housing, and other civil rights laws pertaining to affordable housing.
Thorough and working knowledge of psychiatric and co-occurring disorders is imperative.
Requires knowledge of DSM-5 codes and descriptions, psychotropic medications and crisis intervention.
Knowledge of community based behavioral health services preferred.
Must be able to maintain excellent member and family relationships and provide excellent customer service.
Requires effective interpersonal, written and oral communication skills.
Must be able to follow direction, use sound judgment, solve problems, manage time, identify priorities, and stay organized.
Must be competent in the use of electronic medical records software, as well as in the use of a computer, printer, copier, and telephone. Preferred typing skills of 25 to 40 WPM. Occasional use of fax machines, security systems, and other office equipment.
Must be highly proficient in the use of Microsoft Office software, including Outlook, Word and Excel.
Must be able to effectively use the internet and various web browsers.
WORKING CONDITIONS and DRIVING
Travel between Southwest Network sites as well as in the community is required. Must have a registered and reliable vehicle that meets Arizona state law standards and meet the insurance standards of Southwest Network.
Work is performed in the community as well as an office setting; must be able to move about; occasionally exposed to outside weather conditions.
Must be able to remain in a stationary position for long periods of time and position self to reach items under or above desks, in storage, or in areas not easily accessible; some lifting also required.
After hours, on-call rotation. When on call, serves as first responder to any crisis situation that may arise. Evening or weekend hours required on an as-needed basis.