NYC Health + Hospitals/Metropolitan is the community hospital of choice for residents of East Harlem, northern Manhattan, and neighboring communities. The hospital provides culturally-sensitive care in a welcoming and hospitable setting, emphasizing primary care medicine and utilizing the latest advances in medical science. Metropolitan delivers high quality health services with compassion, dignity, and respect to all, without exception. Since its founding in 1875, the hospital has been affiliated with New York Medical College, representing the oldest partnership between a hospital and a private medical school in the United States. Metropolitan is a part of the NYC Health + Hospitals, the largest municipal hospital and health care system in the country.

At NYC Health + Hospitals, our mission is to deliver high quality care health services, without exception. Every employee takes a person-centered approach that exemplifies the ICARE values (Integrity, Compassion, Accountability, Respect, and Excellence) through empathic communication and partnerships between all persons.

Work Shifts

8:00 A.M - 4:00 P.M

Job Description

PURPOSE OF POSITION:

Individuals with serious mental illness and/or substance use disorder face many barriers to safe discharge and access to continuity of care such as lack of family and social supports, stigmatization and social determinants such as homelessness, in addition to the challenges posed by their diagnosis. Lack of access to continuity of care poses a high risk for rapid revisits to ED or readmission. Stabilization in the community and continuity of care after emergency room visit require implementing "bridging strategies" that coordinate care between acute care and outpatient and community services. A key quality improvement measure for NYC Health + Hospitals is increasing patient attendance at follow-up appointments after emergency room visits for mental health or substance use disorders. Establishing a connection to outpatient services within 7 days after an ED discharge significantly reduces the risk of readmission
Aftercare follow up worker will be responsible for providing care coordination services after the ED visit. The successful candidate will work closely with the clinical team and community resources to help patients navigate the healthcare system and access necessary resources for optimal recovery.

RESPONSIBILITIES:
• Coordinate with E D team to identify patients in need of care coordination support especially high-risk patients
• Review ED discharge plan with each patient discharged from ED, identify barriers to following up with discharge plan and connecting to continuity of care
• Run Epic discharge reports on a daily basis for ED/CPEP to identify target patient lists
• Contact patients within 24-48 hours of discharge to assess their post-discharge needs and develop a personalized aftercare plan
• Coordinate with healthcare providers, family members, and community resources to ensure that patients have access to ap propriate follow-up care, including therapy, medication management, and other supportive services such as transportation
• Help patients connect to a behavioral health as well as primary care provider, attend appointments, and fill prescriptions
• Support and motivate patients to achieve their health goals by coaching them through behavior change and identifying their strengths and community support systems
• Identify and coordinate with existing community support services e.g. ACT, Health Home,
other Care Management services, MCOs that can connect the patient to continuity of care and ongoing support within the community
• Educate patients regarding available community services, health services, and patient rights; provide feedback from patients to H+H to inform quality improvement efforts
• Monitor patients' progress and provide ongoing support and encouragement to help them meet their recovery goals
• Document each patient encounter in the electronic medical record (Epic) and use other electronic systems
• (e.g. Find help) in accordance with established policies and procedures
• Participate in team meetings and trainings to stay informed of best practices and healthcare updates
• Perform other duties as assigned
• All above duties m ay change at the discretion of the department head/supervisor according to the needs of the services.

Minimum Qualifications

For Appointment to Level I
1. One year of full-time experience in a government agency or community organization in providing community services to the public or in assisting members of the community in obtaining community services; or
2. Completion of an approved six month training program of combined classroom training and on-the-job experience in community liaison work, plus six months of full-time experience as described in 1 above.

For Appointment to Level II
In addition to meeting the qualification requirements of Assignment Level I, appointment to Level II requires:
1. Two additional years of full-time experience in counseling, community work or community health activities in a government agency or community organization engaged in providing community services to the public, assisting members of the community in obtaining community services or maintaining liaison with schools, community organizations or other government agencies for the purpose of providing assistance and obtaining participation and support for implementation of community or public service programs; or
2. Education and/or experience equivalent to 1 above. Study at an accredited college in sociology, psychology or other behavioral science may be substituted on the basis of 30 semester credits for each year of the experience described above. However, all persons must have at least one year of the full-time experience described above.

For Appointment to Level III
In addition to meeting the qualification requirements of Assignment Level II, appointment to Level III requires:
1. One additional year of full-time experience as described in 1 above.

For Appointment to Level IV
In addition to meeting the qualification requirements for Assignment Level III, appointment to Level IV requires:
1. One additional year of full-time experience.

In addition, you can submit your resume to METCareers@nychhc.org with the Job Title and Job ID # of the job posting that you applied to in the subject line of the email.

NYC Health and Hospitals offers a competitive benefits package that includes:

• Comprehensive Health Benefits for employees hired to work 20+ hrs. per week
• Retirement Savings and Pension Plans
• Loan Forgiveness Programs for eligible employees
• Paid Holidays and Vacation in accordance with employees' Collectively bargained contracts
• College tuition discounts and professional development opportunities
• Multiple employee discounts programs