Sr. Case Manager N

For over 125 years, Catholic Charities Brooklyn and Queens has been providing quality social services to the neighborhoods of Brooklyn and Queens, and currently offers 160-plus programs and services for children, youth, adults, seniors, and those struggling with mental illness.

Kingsborough Transitional Team and Kingsborough Transition Team provide intensive wraparound services for the severely chronically mentally ill who have a history of recent psychiatric hospitalization. This critical time intervention is provided for a duration of 6 to 9 months. Service includes coordination of psychiatric and medical care, community access to services, as well as connections to housing services, counseling, nursing and medication management.

This is a direct care position assigned to the Pathway Home transition team in Brooklyn, embedded at Kingsborough State Psychiatric Center. The Sr. Case Manager will work on a newly funded field-based innovative Care Transition team that serves individuals transitioning to the community from a higher level of care. As a member of the Pathway Home™ multi-disciplinary team, the Sr. Case Manager will work under the supervision of the Team Leader.

The role will involve facilitating transition from one level of care to the community by addressing the preparatory needs of participants in the early stages of recovery, discharge planning, development of daily living skills, and coping mechanisms through group and individual work in the community. The team will follow participants into the community using the Pathway Home™ model of care to ensure that they become both linked and engaged with identified community providers and that their support network is sufficient to meet their needs.

The role will require on call coverage and a willingness to work flexible hours.

• Engage in-patient clients at acute care hospitals, state psychiatric centers or state operated residences and participate in the coordination of their discharge; beginning from referring location with involvement in transition planning, including a needs assessment of community transition supports essential to stabilizing the client.
• Provide intensive emotional and practical support to clients as they transition back into their communities.
• Conduct home visits as assigned.
• Accompany clients to appointments with community-based treatment providers and other services as needed.
• Individual sessions with clients emphasizing prevention and preparing for independent community living and the promotion of optimum mental and emotional health. May require helping clients deal with issues associated with but not limited to family and social relationships; stress and symptom management; activities of daily living; medication management; and housing readiness.
• Work with clients and their housing providers to resolve clinical issues that are impacting on the participant’s ability to obtain, manage, and retain supportive housing.
• Foster connection and engagement with community-based organizations that promote a sense of purpose, physical wellness, education, employment, socialization, and community involvement.
• Community navigation including accompanying clients to first behavioral health and medical appointment, travel training, reengagement in community care, referral to services with ability to identify and address potential services and barriers to obtain and maintain such services.
• Establish collaborative working relationships with referring treatment teams and other partners and plan with them for appropriate discharges for clients.
• Review documentation and conduct comprehensive psychosocial assessments to determine the medical, psychiatric, housing and other social needs in…