Develop and promote a supportive professional relationship with patients
· Assess social, physical, and mental wellbeing (social determinants of health, PREPARE, ASSIST)
· Develop, coordinate, and implement an appropriate individual service plan (ADD To our TP or should we develop one)
· Foster and cultivate relationships with agencies and service providers
· Provide supportive individual and/or group support to assist patients to modify attitudes and behaviors as needed.
· Complete Initial comprehensive assessment of the client’s needs and their support systems using PREPARE and/or Social Determinants of Health
· Monitor patient progress and reassess case management plans as needed.
· Coordinate and link patient’s Initial comprehensive assessment of the patient’s needs and person support systems.
· Coordinate and link patients to all necessary services that are culturally and linguistically appropriate to implement the plan.
· Conduct periodic re-evaluation and revision of the plan as necessary over the life of the client..
· Participate in case conferences with clinical providers as needed to sustain and improve patient quality of life;
· Develop ongoing relationships and contacts with outside agencies.
· Participates in professional development activities and maintains professional affiliations.
· Fosters and cultivates relationships with agencies and service providers
· Coordinate and accesses services for clients in areas such as: meals on wheels, transportation, home health aides, homemakers, financial assistance, counseling, preventative health screening, at home medication management, etc.
· Maintain psychosocial documentation regarding individual client’s interventions, problems, issues and follow-up, and resident satisfaction
· Maintain clients’ confidentiality in accordance with HIPPA regulations and protect and be respectful of clients; rights and privacy
· Provide general assistance, advocacy, and education related to supportive services to all clients; provide up to date information and clarification regarding programs such as Medicare, Medicaid, entitlements by reviewing edibility status through annual reassessments.
· Report all unusual incidents and cases of suspected abuse or neglect in accordance to Community Health Services policy and procedures
· Perform any other department or agency-related duties or special projects as directed by supervisor