Position Title: Mental Health Community Support Worker
Position Under Administrative Supervision of: Kerri Anderson
Position Under Clinical Supervision of: LICSW, LIMHP
Position Summary: The Community Support program is designed to:
1. Provide/develop the necessary services and supports to enable clients to reside in the community
2. Maximize the client’s community participation, community and daily living skills, and quality of life.
3. Facilitate communication and coordination between mental health rehabilitation providers that serve the same client.
4. Decrease the frequency and duration of hospitalization. Community Support Workers provide client advocacy, ensure continuity of care, support clients in times of crisis, provide/procure skill training, ensure acquisition of necessary resources, assist clients with spend downs and other financial insurance coverage programs, and assist the client in achieving community/social integration.
The Community Support Program will provide a clear focus of accountability for meeting client’s needs within the resources available in the community. The role(s) of the Community Support Worker may vary based on client’s needs. Community Support is a service in which the client’s contact occurs outside the program offices in community locations consistent with the individual client choice/need. Community Support is frequently provided in the home and is not facility or office-based. The frequency of contact between the community support provider and the client is individualized and adjusted in accordance with the needs of the client.
1. Facilitate communication and coordination among the mental health rehabilitation providers serving the client;
2. Ensure that the client has a diagnosis of severe and persistent mental illness, as exhibited by the completion of an Initial Diagnostic Interview, no more than 12 months prior to admission to Community Support. The Initial Diagnostic Interview must identify the need for Community Support and outline the needed services and resources for the client.
3. Ensure completion of a strength-based needs assessment which may include skills inventories, interviews and other tools to develop treatment and rehabilitation plans which must be completed within 30 days of admission by the rehabilitation team or team members.
4. Ensure the completion of an Individual Treatment, Rehabilitation, and Recovery Plan for each client served. The Individual Treatment, Rehabilitation, and Recovery Plan shall be completed within 30 days following the admission of the client and reviewed and updated every 90 days or as often as clinically necessary thereafter while receiving services.
The Individual Treatment, Rehabilitation, and Recovery Plan shall be based on the results of comprehensive assessments and is developed with the client’s involvement and through an interdisciplinary team process. The Individual Treatment, Rehabilitation, and Recovery Plan shall include methods and interventions to address: activities of daily living, community living skills, budgeting, education, independent living skills, social skills, interpersonal skills, psychiatric emergency/relapse, medication management including recognition of signs of relapse and control of symptoms, mental health services, physical health care, vocational/educational: services, resource acquisition, and other related areas as necessary for successful living in the community.
5. Ensure the Individual Treatment, Rehabilitation, and Recovery Plan that encompasses the supportive/rehabilitative interventions that will be directly provided by the Community Support Program.
6. Identify the provision of services/interventions identified in the Individual Treatment, Rehabilitation, and Recovery Plan as the responsibility of other rehabilitative service providers.
7. Develop and implement strategies to assist the client in becoming engaged and remaining engaged in medically necessary mental health treatment and psychiatric rehabilitation services.
8. Provide service coordination and case management activities, including coordination or assistance in accessing medical, social, education, housing, transportation or other appropriate support services as well as linkage to other community services identified in the Individual Treatment, Rehabilitation, and Recovery Plan.
9. Facilitate communication between the treatment and rehabilitation providers and with the primary care physician/psychiatrist serving the client.
10. Monitor client progress of the services being received and participate in the revision of the Individual Treatment, Rehabilitation, and Recovery Plan as needed or at the request of the client.
11. Provide contact as needed with other service provider(s), client family member(s), and/or other significant people in the client’s life to facilitate communication necessary to support the individual in maintaining community living.
12. Assist the client in the developing, evaluating and updating a crisis and relapse prevention plan. This plan shall be coordinated with any other rehabilitative service and include the client’s natural supports. Provide therapeutic support and intervention to the client in time of crisis. If hospitalization is necessary, facilitate, in cooperation with the inpatient treatment provider, the client’s transition back into the community upon discharge.
13. Participate with and report to the treatment/rehabilitation team on the progress of the client in areas of medication compliance, relapse prevention, social skill acquisition, application, education, substance abuse, and ability to sustain community living.
14. Monitor medication compliance.
15. Assist the client with all health insurance issues including Share of Cost eligibility issues. Ensures client understanding of financial benefits and procedures to use those benefits such as Medicaid spend downs, AABD, SSI and SSA, etc.
16. Performs other duties as assigned by the supervisor which are consistent with the position and in compliance with agency policies and procedures.
Education Requirements: Community Support Worker will possess a bachelor’s degree in psychology, sociology, or related human services field OR have completed two years of course work in the human services field and have two years of experience/training in the human services field OR have completed two years of course work in the human services field and have two years of lived recovery experience.
Direct Care staff having a bachelor's degree in psychology, sociology or related human services field or two years of course work in the human services field and two years of experience/training in the human services field or two years of lived recovery experience is acceptable. All community support workers shall be trained in rehabilitation and recovery principles and shall have demonstrated skills and competency. Each staff shall have demonstrated skills and competency in treatment with individuals with mental health diagnosis.