Care Coordinator (RISE, Spanish/English)
https://bhchpjobs.applytojob.com/apply/niVGxu9zZE/Care-Coordinator-RISE-SpanishEnglish
Job Summary: Hours: Monday-Friday, 8:30 AM- 5:00 PM The Care Coordinator
will be an integral part of a multidisciplinary team within our RISE
(Reentry Initiatives for Support and Empowerment) program working with
homeless, incarcerated individuals in Suffolk County. BHCHP has
partnered with the Suffolk County Sheriff?s Department (SCSD) at two
county jails to outreach to this population. This program aims to engage
this population prior to release, to connect with external Medication
for Opioid Use Disorder (MOUD) partners to improve transitions of care
for these individuals upon release, and ultimately to improve outcomes
related to drug use in this population who are at a particularly
high-risk of fatal overdose upon release. The Care Coordinator will join
an interdisciplinary team of doctors, nurses, a clinic/project director,
therapist, care coordinators, recovery coach and others working together
to support incarcerated individuals with a diagnosis of opioid use
disorder and those at high risk of fatal overdose prior to release, on
the day of release, and in the post-release period to provide the
following: Pre-release support including Critical Time Intervention,
case management, behavioral health services, psychiatry, recovery
support groups, legal case management, MOUD evaluations, HIV and HCV
screening and referrals, and recovery coaching. Services are provided
directly in in-person at the jail when permitted, or by telehealth
encounters. Support on day of release from jail including in person
visits to the jail or courthouse, transportation support, care
coordination, accompanying individuals to medical appointments and to
obtain prescriptions, naloxone provision and naloxone training for
overdose reversal. Post-release support including a continuation of
pre-release supports, as well as support with direct MAT provision,
psychiatric treatment/medication bridging, individual therapy, and
Hepatitis C (HCV) treatment. BHCHP utilizes a harm reduction model to
recovery and the care coordinator will be working with individuals at
all stages of recovery. This position offers a tremendous opportunity to
work at the intersections of the opioid epidemic, incarceration, and
homelessness, to address the root causes of illness in a collaborative
team-based community health center context. Applicants must be
proficient in both English and Spanish. Responsibilities: Meet with
patients in jails to assess patients? financial, housing, legal,
addiction treatment, and other social service needs in the pre-release
period. Develop comprehensive patient centered care coordination plans
to address these needs and provide support and follow up in the
post-release period; Work with program participants to ensure they are
effectively bridged to community-based OUD treatment post-release,
including mitigating lapses in care associated with waiting lists and
other barriers. Obtain program participants? consent to communicate with
community-based OUD treatment providers, in accordance with HIPAA and 42
CFR; obtain informed consent to participate in the program evaluation
and assist with data collection at baseline and 6-month time points; In
partnership with SCSD staff, provide care coordination services to
enroll or facilitate re-enrollment in insurance coverage for all program
participants prior to or immediately after their scheduled release from
SCSD, to ensure there are no gaps in coverage that would otherwise
preclude individuals from continuing MOUD post-release. Provide care
coordination to support reentry, identify community resources, and
connect participants to medical and social services post-release (such
as transportation, primary care, naloxone, and housing); Support BHCHP?s
Correctional Linkage to care grant by screening individuals for interest
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