Care Coordinator

Support the mental and physical health care of patients on an assigned patient caseload. Closely coordinate care with the patient’s medical provider and, when appropriate, other mental health providers.

Screen and assess patients for common mental health and substance abuse disorders using evidence-based screening tools. Facilitate patient engagement and follow-up care.

Provide patient education about common mental health and substance abuse disorders and the available treatment options.

Systematically track treatment response and monitor patients (in person or by telephone) for changes in clinical symptoms and treatment side effects or complications using an Electronic Health Record (EHR) system.

Support psychotropic medication management as prescribed by medical providers, focusing on treatment adherence monitoring, side effects, and effectiveness of treatment.

Provide brief behavioral interventions using evidence-based techniques such as behavioral activation, motivational interviewing, or other treatments as appropriate.

Provide or facilitate in-clinic or outside referrals to evidence-based psychosocial treatments (e.g. problem-solving treatment or behavioral activation) as clinically indicated.

Participate in caseload consultations with the psychiatric consultant and communicate resulting treatment recommendations to the patient’s PCP. 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.

Document patient progress and treatment recommendations in the EHR and other required systems to be shared with medical providers, psychiatric consultant, and other treating providers when appropriate.

Facilitate treatment plan changes for patients who are not improving as expected or who may need more intensive or specialized mental health care, in consultation with the medical provider and the psychiatric consultant.

Facilitate referrals for clinically indicated services outside of the organization (e.g., social services such as housing assistance, vocational rehabilitation, mental health specialty care, substance use 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.