Community Support Specialist (Relapse Prevention Team)

Responsibilities

Primary Job Functions:

Recovery Engagement and Relapse Prevention

• Provides intensive, community-based engagement and support to individuals identified by the Relapse Prevention Team as having elevated risk for psychiatric hospitalization, crisis utilization, treatment disengagement, homelessness, substance use relapse, emergency department utilization, or other adverse outcomes.
• Establishes and maintains consistent, respectful, recovery-oriented relationships with individuals receiving services.
• Conducts outreach to individuals who have missed appointments, disengaged from services, recently discharged from psychiatric hospitalization or crisis services, or otherwise require increased engagement.
• Utilizes persistent but respectful engagement strategies while honoring the individual’s rights, preferences, autonomy, culture, and dignity.
• Assists individuals in identifying barriers to treatment participation and works with the interdisciplinary team to develop practical strategies to address those barriers.
• Supports engagement of individuals transitioning from higher levels of care, including crisis services, inpatient psychiatric hospitalization, residential services, or other intensive services.

Care Coordination and Transitions

• Supports the Relapse Prevention  Team’s coordination of behavioral health, primary care, substance use, crisis, hospital, housing, transportation, employment, social service, and other community resources.
• Participates in post-discharge follow-up activities to promote continuity of care and reduce avoidable readmissions, crisis episodes, and emergency department utilization.
• Assists individuals in understanding and following their individualized treatment and recovery plans.
• Assists with appointment scheduling, appointment reminders, referrals, transportation coordination, and communication with identified service providers.
• Facilitates communication among members of the individual’s interdisciplinary treatment team within the scope of the position and organizational policy.
• Supports transitions between levels of care and communicates relevant information to appropriate team members in accordance with privacy requirements.
• Assists individuals with identifying and accessing community resources related to housing, food, transportation, benefits, employment, education, healthcare, and other identified social determinants of health.
• Documents care coordination activities and outcomes in the electronic health record in accordance with organizational policy and applicable regulatory requirements.

Monitoring and Follow-up

• Maintains regular contact with assigned individuals according to the level of support identified by the Relapse Prevention  Team.
• Monitors identified indicators of increased risk or disengagement and promptly communicates concerns to the appropriate team member.
• Assists the interdisciplinary team in identifying changes in functioning, living situation, support systems, treatment participation, substance use, or other circumstances that may affect the individual’s stability.
• Provides timely notification to the appropriate licensed or qualified staff when an individual’s presentation or circumstances indicate a need for clinical reassessment, crisis intervention, medication evaluation, or another higher level of care.
• Participates in team review of individuals with repeated hospitalizations, crisis center presentations, emergency department visits, treatment non-adherence, or other identified high-risk indicators.
• Supports implementation of individualized relapse-prevention, crisis-prevention, safety, and recovery strategies developed by qualified members of the treatment team.

Crisis Prevention and Response

• Recognizes signs and symptoms indicating potential psychiatric, substance use, medical, behavioral, or environmental crisis.
• Utilizes approved organizational procedures for responding to individuals experiencing an increase in risk or behavioral health symptoms.
• Immediately communicates significant safety concerns, suicidal or homicidal statements, significant behavioral changes, suspected abuse or neglect, medical emergencies, or other identified risks to the appropriate supervisor or qualified clinical professional.
• Activates emergency services when required by organizational policy, applicable law, or the immediate safety needs of the individual or others.
• Assists with follow-up after crisis intervention, emergency department visits, crisis center encounters, or psychiatric hospitalization as directed by the treatment team.
• Participates in de-escalation and crisis-prevention activities within the scope of training and position responsibilities.
• Does not independently diagnose, conduct clinical risk assessments requiring a licensed professional, prescribe or administer medication, or provide clinical interventions outside the individual’s qualifications and authorized scope of practice.

Documentation

• Completes timely, accurate, objective, and clinically relevant documentation of all assigned contacts and services.
• Documents the purpose of the contact, individual’s response, interventions/support provided, progress or barriers identified, follow-up needs, and appropriate disposition in accordance with organizational requirements.
• Ensures documentation supports the individual’s treatment plan, medical necessity, continuity of care, and services actually provided.
• Completes documentation within organizationally established timeframes and applicable Alabama Medicaid, CCBHC, Joint Commission, and other regulatory requirements.
• Maintains accurate information regarding outreach attempts, successful contacts, missed appointments, referrals, transitions, and follow-up activities.

. Interdisciplinary Team Participation

• Participate in interdisciplinary treatment team meetings.
• Collaborate with psychiatrists, nurses, therapists, case managers, peers, primary care providers, and community partners.
• Assist with integrated treatment planning.
• Communicate significant changes in physical or behavioral health.
• Participate in case reviews for high-risk patients.

Quality Improvement

• Participate in Performance Improvement activities.
• Participate in CCBHC quality initiatives.
• Assist with collection of quality indicator data.
• Support population health reporting.
• Participate in audit readiness activities.
• Assist with compliance monitoring activities.

Performance Standards

Performance will be evaluated based upon:

• Compliance with Alabama Medicaid Chapter 105.
• Compliance with CCBHC Certification Criteria.
• Timeliness of documentation.
• Quality of care coordination.
• Patient satisfaction.
• Accuracy of medical documentation.
• Participation in interdisciplinary care.
• Compliance with quality improvement initiatives.
• Adherence to organizational policies and ethical standards.

Physical Requirements

• Frequent standing, walking, sitting, bending, reaching, and keyboard use.
• Frequent travel within the community.
• Ability to lift up to 30 pounds.
• Ability to perform venipuncture and other clinical procedures.
• Ability to respond appropriately during behavioral health crises.
• Ability to operate standard clinical equipment.
• Ability to work in outpatient clinics, community settings, hospitals, shelters, and patients' homes when assigned.

Qualifications

Minimum Qualifications:

High School diploma or equivalent.  Must be 23 years of age, maintain a valid Alabama driver license and an acceptable driving record, and have proof of current liability insurance.

To be obtained within 6 months of employment:

• Knowledge of psychiatric disorders in the adult population
• Knowledge of cultural diversity
• Knowledge of behavior management, crisis intervention and interventions common to acute psychotic consumers; as well as, to non-violent crisis intervention practices
• Knowledge of psychiatric rehabilitation principles
• Knowledge of available community employment resources
• Knowledge of educational methods appropriate to adults with psychiatric disorders