The Partners in Recovery Network believe that recovery from mental illness is an outcome we can achieve by harnessing the wisdom of service recipients and their families with the knowledge of skilled and caring professionals. We believe that everyone has intrinsic strengths that can be used to develop an individualized recovery plan. Partners in Recovery staff model and practice recovery principles in all activities including hope, empowerment, encouragement, support, self determination, and connection to the community. Staff serve as positive role models demonstrating professional and caring attitudes and behaviors toward the individuals we serve, their families, co-workers and guests. Staff contribute to effective teamwork by combining skills and energies in a coordinated effort with individuals we serve, their families, supervisors, co-workers and outside agencies.
As a member of the clinical team, participates in the assessment and service plan development and implements services to consumers in accordance with their individualized service plan (ISP). Communicates and documents consumer’s progress toward their recovery.
Essential Duties and Responsibilities:
1. Works collaboratively with the clinical team to engage, educate, communicate, and coordinate care with consumer, their family, behavioral health, medical and dental providers, community resources and others in ensuring that all services prescribed in the individualized service plan are implemented.
2. Provides supportive services including, but not limited to, the following:
- Assistance in maintaining, monitoring and modifying covered behavioral health services;
- Brief telephone or face to face interactions with a person, family or other involved party for the purpose of maintaining or enhancing a person’s functioning;
- Assistance in finding necessary resources other than covered services to meet basic needs;
- Serves as a point of contact and to ensure ongoing collaboration including the communication of appropriate clinical information with other involved parties as appropriate and coordination of care with a person’s family, behavioral and general medical and dental health care providers, community resources, and other involved supports including educational, social, judicial, community and other State agencies;
- Ensures the provision of all covered services identified on the service plan; referrals to community resources as appropriate and coordination of care activities related to continuity of care between levels of care and across multiple providers, services and supports;
- Provides outreach and follow-up of services including, but not limited to, crisis and missed appointments to ensure adequate resources are available and in place;
- Participates in staffings, case conferences or other meetings with or without the person or his/her family participating;
- Screens and assesses all persons on caseload for financial entitlements (AHCCCS, SSI/SSD etc.); completes AHCCCS applications on all consumers on caseload meeting criteria;
- Provides transportation to consumer as appropriate and determined by the clinical team;
- Ensures that transfers to out-of-area, out-of-state or to an Arizona Long Term Care System (ALTCS) contractor, are coordinated as applicable;
- Ensures the development and implementation of transition, discharge and aftercare plans prior to discontinuation of behavioral health services.
3. Performs all case management functions associated with caseload including participating in the assessment and service planning processes; including identifying the need for further or specialty evaluations.
4. Collaborates with the person and his/her family or significant others to implement an effective service plan, explaining the available clinical options to the team, including the advantages and disadvantages of each option.
5. Maintains the person’s comprehensive clinical record, including documentation of activities performed as part of the service delivery process (e.g., assessments, provision of services, coordination of care, discharge planning).
6. Provides continuous evaluation of the effectiveness of treatment through the ongoing assessment of the person and input from the person and relevant others resulting in modification to the service plan as necessary.
7. Pursues best practice outcomes for person with mental illness including continuing education, employment, independent housing and community tenure.
8. Other duties as assigned.