Central Health's Medical Respite Program is an innovative initiative providing immediate access to emergency housing, medical care, and case management support for individuals experiencing homelessness who are recovering from acute illness. While in the program, participants focus on improving their physical health and have the opportunity to address social needs such as securing housing and accessing benefits. The Medical Respite Case Manager plays a pivotal role in the multidisciplinary team by providing intensive case management to patients enrolled in the program. This role supports participants throughout their medical respite stay, including welcoming new participants, engaging with them daily, and coordinating their social needs. The case manager also facilitates connections to medical and behavioral health services. Key responsibilities include crisis management, timely referrals to appropriate treatment programs for substance abuse, physical health, and mental health. Additionally, the case manager assists participants in accessing benefits and entitlements and identifying affordable housing as part of a comprehensive approach to ending homelessness and supporting self-sufficiency.

Essential Functions
· Develops individualized treatment plans and psychosocial goals for short- and long-term care plans by assessing individual needs, strengths, barriers and readiness to change
· Provides crisis intervention services (assessment, evaluation of risk, referral and follow up) and effectively deescalate heightened situations with patients experiencing trauma, exacerbated mental health symptoms, and behavioral complexity
· Provides goal oriented and short oriented services (engagement, case management, counseling linkage) with complex psychosocial needs, and educates patients on available community resources
· Teaches patients through structure and modeling appropriate expectations and guide them on following through with their tasks, to include helping patients identify and manage challenges or barriers in navigating health and government benefits
· Works collaboratively with patients on discharge planning by reviewing potential transitional housing programs, assisting with room rental search and applications for housing units, and assist patients indirectly and directly with housing survey
· Collaborate with housing specialists and/or other resources to identify and address psychological, social and medical needs
Essential Functions
· Works collaboratively with treatment team, community resources and partner agencies involved in patient’s care
· Participates in weekly case conference with multidisciplinary respite team to discuss patient’s care plan, and attends all respite trainings in a timely manner, huddles, and other meetings related to quality improvement, assurance, and patient care
· Assists respite team as needed in patients in coordinating transportation for appointment, picking up medications and other support services, and communicate with family or next of kin as able to inform and coordinate treatment and discharge plan
· Accompany patients to appointments as needed, and assists patients in applying for SNAP benefits,
Transportation, screens SSDI/SSI, and procuring birth certificate and ID
· Evaluate patients’ insurance coverage and assist on renewal or enrollment to Medicare, Medicaid or transferring out of state or out of county insurances
· Assist in redcap data collection to document needs addressed and ongoing needs of patients at time of discharge from respite program

MINIMUM EDUCATION:

• Bachelor’s degree in social work or similar field required

MINIMUM EXPERIENCE:

• Two years experience in a field related to social work, case management or counseling individuals in crisis/trauma situations required.
• Preferred experience: Experience (work or internship) in a healthcare setting. Background in managing populations with complex medical needs and
  those experiencing homelessness. Experience in navigating community resources, how to access, obtain,
  and manage

Required:

• Valid driver's license and Basic Life Support (BLS) ‐ Obtained through approved American Heart Association