As a mission-driven organization, the core values of, and the services offered at Sea Mar are based on the belief that everyone deserves to be respectfully treated in a way that preserves dignity and enhances self-worth. Sea Mar is an advocate for its patients, and aims to achieve industry-leading, patient- centered, culturally-aware services.
Sea Mar employees serve as an extension of this mission and demonstrate their commitment to an excellent patient experience by:
• Understanding and empathizing with patient needs
• Surpassing patient expectations
• Demonstrating a high level of integrity and work ethics
• Exhibiting compassion and commitment
• Advocating for social justice
• Taking pride in individual work as well as that of the team
• Continually learning to stay current with industry standards, best practices and technology
• Utilizing AIDET skills at all times
As a Sea Mar employee, the individual in this position commits to adherence to these values to their utmost ability and endeavors to strengthen and embody this mission daily.
The duties and responsibilities of this position include, but are not limited to, the following:
• Actively participate in the interdisciplinary team huddles and work to identify patients’ social and behavioral health needs. Huddles may be virtual and/or in-person as time and number of care teams allow.
• Identify patients’ needs and work with patients to create self-management goals utilizing Motivational Interviewing skills.
• Develop treatment plans with patients, in consultation with other staff, to address identified emotional needs and behavioral problems.
• Work with patients to create self-management goals utilizing Motivational Interviewing skills. Create self-management goals for no less than 90% of all patients within the first two visits.
• Gather information regarding past mental health services to be used in the individual’s treatment plan development.
• Conduct follow up visits in-person or by telephone to determine progress of self-management goals.
• Refer patients to psychiatric services as appropriate. Gather records and background information as needed by the community mental health center (See Policies and Procedures).
• Attend sessions with psychiatric service providers to insure accuracy of presentation and that identified needs are addressed. Provide monitoring regarding the effects of medications, and feedback to the psychiatrist regarding effects/side effects.
• Provide brief individual counseling, in coordination with other systems, as needed.
• Provide suicide risk assessment and develop treatment plans to address suicidal ideation or gestures. Use case management, as needed, and build community support to provide follow through. Provide other crisis stabilization as needed.
• Provide mental health service referrals to patients prior to or following admission, and exchange information with outside service providers.
• Ensure that quality and performance requirements based on grants, contracts, and organizational priorities are met. i.e. Clinical Quality Measures, Patient Satisfaction Measures, and Meaningful Use Measures.
• Conduct required assessment screenings and follow up interventions as per protocol. Perform additional screenings such as AUDIT/DAST for substance and alcohol use/abuse when indicated to identify care needs.
• Monitor patient for medication adherence and relay findings to the medical provider and/or specialists of other disciplines involved in patient care. Encourage the patient to discuss issues regarding medication adherence with their provider at their next visit.
• Participate in weekly caseload consultation sessions with a BH Clinical Supervisor. Facilitate treatment referrals to Behavioral Health sites as needed, assist in the step down or step up process to the appropriate level of care, and maintain active communication with other members of patient’s care team.
• Actively coordinate with community providers and case managers on behalf of patients.
• Coordinate/facilitate communication between patient, family/natural supports, primary care physician, consulting psychiatrist and members of the Clinical Care Team.
• Document all encounters according to organizational policies and procedures utilizing appropriate electronic health records system. Close encounters within 24 hours of service.
• Gather and monitor outcome measures as part of quality improvement process. Participate in the Health Home meeting and participate in all PDSA activities related to depression screening and medication management.
• Participate in Patient Centered Medical Home recognition application process.
• Attend all quarterly joint team meetings.
• Perform other duties as assigned.
Performance Metrics:
• Must have 10 or more patient encounters a day, schedule them in Cerner, and chart care plan in EHR. A least 5 encounters should be face-to-face direct services, each no more than 30 minutes. Remaining encounters will be phone calls to clients.
• Adhere to schedule and be prepared to provide services by 8am each day.
• Apply AIDET skills at all times while providing services to clients.
• Adhere to the guidelines outlined in the Bidirectional Model of Care.
• Create Self-Management goals with 90% of patients who have a face-to-face direct service encounter.
• Have at least two encounters a month for each patient in caseload as dictated by medical necessity.
• Resolve patient needs within six months or coordinate the transition of care to a higher level of service.
• Conduct one PHQ9 per client per month. If patient does not show improvement in PHQ9 score by five points or 50% by the end of a six-month period, then patient should be staffed with Clinical Supervisor and transferred to a higher level of care.
• Attend weekly consultation sessions with the Behavioral Health Clinical Supervisor and send summary to the Clinical Care Team.
• Close chart notes within 24 hours of service.
• Communicate with PCPs via clinical case summaries sent on a quarterly basis.
Qualifications