Pre-Transition Care Manager

Care managers will provide direct-service and clinical oversight to Colbert and Williams Class Members transitioning out of SNFs (Skilled Nursing Facilities) and SMHRFs (Specialized Mental Health Recovery Facilities).  Care Managers will provide assessment services to residents and serve as an advocate for residents to help facilitate a positive transition from nursing home living to independent living in the community.  They will assess the residents’ readiness to discharge from the facility setting and collaborate with members to complete a Comprehensive Service Plan to facilitate transition to independent living and/or a less restrictive environment.  They will routinely interface with nursing home employees to obtain records, advocate on behalf of the resident, and coordinate any services as needed.  They will collaborate with Outreach Specialists, Transition Coordinators, Nurses, and Occupational Therapists to facilitate a safe transition to the community.

The Care Manager will provide client-centered, strengths-based, and trauma-informed services to clients with severe mental illness and co-occurring substance abuse/addiction disorders utilizing a harm reduction approach.   

 

 Responsibilities: 


* Meet regularly with Class Members at assigned nursing facilities in Chicagoland and surrounding suburbs.  


* Oversee and coordinate all service activities for Colbert and Williams Class Members transitioning out of nursing facilities 


* Provide education regarding rights to an assessment under the Williams and Colbert Consent Decree Program, and services available within the community to support independence and recovery. 


* Utilize motivational interviewing skills to engage Class Members in therapeutic and collaborative ways.   


* Facilitate phone or face-to-face discussions with collateral contacts (i.e.

family, friends, and/or guardians), and key facility employees (i.e.

Director of Nursing, Social Services, Administrator, etc.) to obtain information about the Class Member.   


* Complete all Illinois Department of Human Service assessment documents electronically and submit to appropriate agencies according to submission guidelines. 


* Conduct and complete strengths-based Assessments of consenting Class Members (initially, annually, and/or quarterly upon request). 


* Collaborate with Class Members and team members to develop a person-centered Comprehensive Service Plan.

These plans must be developed and updated at specific intervals and submitted to appropriate IDHS contacts per the service plan reporting procedures. 


* Complete all clinical documentation in a timely and thorough manner. 


* Communicate effectively with the team for purposes of consultation and information sharing. 


* Participate in team meetings to coordinate and support pre-transition services. 


* Participate in hosted/scheduled training sessions, webinars, and/or teleconferences. ...