Create and/or enhance existing person/family-centered care plans that identify the patient's goals, objectives, strengths and preferred involvement of natural supports as well as coordination with internal and external providers.
Assess the patient's and family's needs on a continual basis throughout the course of treatment.
Assist with scheduling and completing all internal and external provider appointments.
Work with patient to identify and meet needs impacting social determinants of health, including housing, food, clothing, transportation, employment and academic needs.
Interact with other team members to provide comprehensive and timely assistance in resolving issues that are barriers.
Coordinate with internal and external providers to ensure a holistic approach to care that considers all areas of an individual's life, including the individual's wants, goals, and treatment interventions.
Document services in the electronic health record according to Amoskeag Health procedures in a timely manner.
Contact patients at least two times per month; maintaining a caseload of 20-30 individuals in service.
Develop and maintain collaborative working relationships with internal and external referral resources including, but not limited to: schools, mental health clinics, substance use treatment providers, DCYF, inpatient psychiatric and substance use facilities, justice staff, inpatient acute care hospitals and hospital outpatient clinics and other community/regional supports.
Assist the patient in developing and/or strengthening natural supports who will participate in care coordination activities.
Assist with data collection and reporting.
Establish positive and supportive relationships with patients while applying appropriate boundaries.
Effectively work with target populations from diverse backgrounds and assist in removing barriers to services.
Help maintain a list of community resources for successful external referrals.
Maintain confidentiality of information concerning consumers and family members.
Work with Prenatal Team, MAT team, supervisor, and interpreters to identify language and low-literacy materials to use with patients to provide information and resources to better manage their health condition(s).
Assess potential resources to provide education to patients such as: Pamphlets, videos, posters, classes, one on one education and share with Prenatal and MAT Team for consensus and planning.
Prepare and update Perinatal SUD intake packets as needed.
Build and maintain relationships with community organizations to exchange information and recruit potential Patients.
Assist with set up and participate in community meetings and events to provide education