Purpose:
Care Manager staff coordinate the care and services to clients who are transitioning from nursing homes and long-term care facilities to the community. Care Management staff must demonstrate leadership and accountability in managing the pre and post transition activities. This includes but is not limited to being able to navigate changes at the system or individual level, the ability to clearly communicate with the interdisciplinary team, Clients, supports and providers, and the ability to advocate for them and resolve conflicts.
Essential Responsibilities, include but are not limited to:
- Care Managers will develop an initial comprehensive person-centered service plan for each client together with periodic updates.
- Care Management staff are responsible for monitoring and implementing all service plans. This status needs and preferences, to ensure changes are made where necessary to benefit the client.
- Care Manager will Educate Clients in areas identified in the Service Plan such as medication management, Healthy lifestyle, psychosocial needs and Self-Management skills.
- Care Manager will collaborate with the Clients, the interdisciplinary team members, other providers, health plan, and other supports to ensure the Service Plan is being appropriately followed.
- Provide linkages to needed treatment (i.e. Substance Use, trauma treatment, individual therapy
- Facilitate discharge planning with the Client, facility staff, Medicaid Managed Care health plan care coordinator, family/guardians, and other key stakeholders.
- Provide brief, supportive goal directed counseling to clients experiencing difficulty or ambivalence about making choices.
- Aid client in obtaining new living arrangements by accompanying them on housing searches for potential apartments.
- Facilitate move to the community which includes but is not limited to assisting with the purchase of household items, arranging transportation, setting up utilities, applying for SNAP benefits and transportation assistance.
- Serve as liaison to a clients managed care company ensuring services and medications are authorized.
- Facilitate and attend medical and psychiatric appointments as needed.
- Provide post-discharge monitoring in client’s home.
- Implement strategy to aid clients in improving or achieving independent living skills.
- Care Management staff must engage in ongoing learning and professional development and seek appropriate certifications as needed.
