GENERAL STATEMENT OF DUTIES:
The purpose of the Behavioral Health Care Manager(BHCM) is to work with an assigned patient population in the primary care setting to promote optimal mental health. Reporting to the Director of Operations, works in partnership with the Behavioral Medicine team and Medical Director, with direction and oversight by Primary Care Physician Leadership, to offer diagnostic assessment and symptom monitoring and care management surrounding behavioral health for patients seen in a CMEP primary care clinic. The BHCM will support the Primary Care Physician by regularly coordinating with the Psychiatric Consultant and guide families and patients through disease self-management, ensure access to an array of community services, administers behavioral health screenings, and conducts and arranges for more detailed assessments when indicated. BHCCM actively manages a caseload of approximately 60 to 120 patients.
ESSENTIAL FUNCTIONS:
- Provide screening, diagnostic assessments, and treatment recommendations for common mental health and substance disorders. Therapy will not be provided by the BHCM.
- Closely coordinate care with the patient’s medical provider and Psychiatric Consultant and when appropriate, and, when appropriate, other mental health providers.
- Addresses and refers for social determinants of care needs, i.e. access to health care, educational, and psychosocial needs of the patient/family. Uses standardized health risk assessment tools.
- Provide patient education about mental health and substance abuse disorders and available treatments.
- Based upon the psychosocial assessment and multidisciplinary care planning, provide brief behavioral, crisis, education, interventions to restore the capacity for social functioning.
- Coordinates patient care through ongoing collaboration with PCP, patient/family, community, and Psychiatric Consultant. Fosters a team approach and includes patient/family as active members of the team. Serves as liaison to acute care hospitals, specialists, and post-acute care services.
- Responsible for developing a comprehensive individualized plan of care and targeted interventions. Continually monitors patient/family response to plan of care, and revises the care plan as indicated.
- Facilitate treatment plan changes for patients who are not improving as expected in consultation with Primary Care Physician and Psychiatric Consultant and who may need more intensive or specialized mental health care.
- Provides patient self-management support with a focus on empowering the patient/family to build capacity for self- care.
- Support psychotropic medication management as prescribed by medical provider, focusing on treatment adherence monitoring, side effects, and effectiveness of treatment.
- Develop and complete relapse prevention self-management plan with patients who have achieved their treatment goals and are soon to be discharged from the caseload.
- Participates in regularly scheduled caseload consultation with the Psychiatric Consultant and communicate resulting treatment recommendations to the patient’s Primary Care Physician. Consultations will focus on patients new to the caseload and those who are not improving as expected under the current treatment plan. Case Reviews may be conducted by telephone, video, or in person.
- Maintains required documentation for all Behavioral Health Care Management activities including patient progress and treatment recommendations in EMR that can be shared with Psychiatric Consultant, other treating providers and codes appropriately for services provided.
- Track patient follow up and clinical outcomes using a registry. Registry function may be within EMR or spreadsheet.
- Works with practice leadership to continuously evaluate process, identify problems, and propose/develop process improvement strategies to enhance Behavioral Health Care Management and Collaborative Care Model.
- Participate in required continuing education opportunities.
SUPERVISORY RESPONSIBILITY
N/A
WORKING ENVIRONMENT/PHYSICAL DEMANDS:
Clinic and office environment, requiring computer usage (prolonged sitting, eye strain)
OTHER DUTIES
Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities and activities may change at any time with or without notice.