Lisa Jones

Works with consumer's Prescribing Clinician, Nurse, and other members of the clinical team to ensure the timely development and implementation of the individual's service plan including all necessary assessments and their crisis plan. Participates in the service plan goal development for each consumer as it related to their rehabilitation goals and the interventions they will need. Provides and oversees the provision of any direct skills training(s) indicated as needed by the individual ACT consumers. Works in close collaboration with the Independent Living Skills Specialist, Housing Specialist, Employment Specialist, and the assigned RSA Vocational Rehabilitation Counselor to ensure coordination of services. Assumes “primary contact” responsibility for a percentage of team consumers to: assure maintenance of accurate, thorough, and current documentation in the medical record (in accordance with policies, procedures, and clinical protocols) for those specific individuals; keep weekly client schedule for those individuals updates, and act as first contact for those consumers and their families. To ensure compliance and adequate services, additional job duties may be required to meet the needs of program and or department, consistent with Copa Health productivity levels.

Collaborated with Crisis Therapist to develop and implement individualized person-centered Treatment Plan that is appropriate for brief intervention. Complete signed Treatment Plan and review with each patient and any other involved parties. Gather collateral from patient and involved parties to provide more thorough assessment of what Behavioral Health Recipient immediate needs are for treatment and discharge. Actively coordinate care for patients to ensure services are coordinated with facility staff. Identified and addressed gaps in service needs for participating parties in service delivery to patient, and make appropriate recommendations to meet patients' needs upon discharge. Collaborated with interdisciplinary treatment team to engage, monitor and communicate with individual ensuring that safety is maintained while meeting individual's needs. Maintained clinic record, including documentation of activities performed as part of service delivery process. Obtained signatures from patient regarding treatment, as necessary. Document all services and patient activities in medical record regarding brief interventions, coordination of care, discharge planning, treatment planning, etc. Maintained working knowledge of Title 36 Involuntary Commitment process. Monitored petition process to ensure timeliness are adhered to, and forms are complete and thorough. When subpoenaed, attended Court Ordered Evaluation hearings. Maintained working knowledge of Maricopa County Regional Behavioral Health Authority (RBHA) system and potential funding sources. Participated in individual and group supervision as required. Participated in ongoing education, including in-services, training, and other activities to maintain and improve competency. Demonstrated competency through post-testing, skill observation, and performance as assessed by direct supervisor.

Identified members in need of rehabilitation/employment supportive services and complete the Vocational Activity Profile (VAP). Provided member referral packets to rehabilitation/employment providers and RSA/ VR program within 7 days of identified need on the ISP. Tracked members in rehabilitation and employment services utilizing a stage of change approach. Coordinated care/services to assist the member in obtaining and maintaining employment and other meaningful community activities. Monitored members in rehabilitation/employment services. Maintained accurate and up to date demographic information related to educational and employment status to engage members as clinical necessary. As necessary, participate in community-wide efforts to increase employment rates for members. Attended regular meetings with the RHBA regarding rehabilitation/employment services. Provided a supportive services overview onsite to ensure awareness of network and not network support services on a regular basis. Provided direct vocational rehabilitation services to the patients assigned to the team. Assisted patients to learn new skills through modeling and roleplay that will assist him or her be successful in the community. Sought out additional opportunities through community and state resources to assist the patient to engage in additional education or skills training. Maintained and cultivated collaborative relationships within the community that provide linkages to skill building, vocational training and education. Facilitated monthly rehabilitation groups as well as individual consults with the member and their family. Served as advisor/peer to other team members to make recommendations and carry out services. Provided services in the field, at the member's home or where the member is at. Worked with member and family to educate on needed services as well as advocate for additional services identified. Worked with members to develop a role for themselves outside of their mental illness, while focusing on expected outcomes of increased employment, Meaningful Community Activity (MCA), independent living status, and social network, as well as decreased substance use/abuse. Taught skill building activities to the member. Documented interaction with each member on a daily basis prior to the end of his or her scheduled shift. Participated in clinical team staffing and provides insight and updates on the member's progress as well as recommendations for additional services that will help the member be successful. Documentation of all services provided will be entered on the same day the service is provided. Case Manager will document at least 25 hours of billable services provided to their caseload.

Worked collaboratively with the ACT team to engage, educate, communicate, and coordinate care with consumer, their family, behavioral health, medical and dental providers, community resources and others in ensuring that all services prescribed in the individualized service plan are implemented. Assistance in maintaining, monitoring and modifying covered behavioral health services. Brief telephone or face to face interactions with a person, family or other involved party for the purpose of maintaining or enhancing a person's functioning; Assistance in finding necessary resources other than covered services to meet basic needs. Served as a point of contact and to ensure ongoing collaboration including the communication of appropriate clinical information with other involved parties as appropriate and coordination of care with a person's family, behavioral and general medical and dental health care providers, community resources, and other involved supports including educational, social, judicial, community and other State agencies. Ensured the provision of all covered services identified on the service plan; referrals to community resources as appropriate and coordination of care activities related to continuity of care between levels of care and across multiple providers, services and supports. Provided outreach and follow-up of services including, but not limited to, crisis and missed appointments to ensure adequate resources are available and in place. Participated in staffing, case conferences or other meetings with or without the person or his/her family participating. Screened and assessed all persons on caseload for financials entitlements (AHCCCS, SSI/SSD etc.); completes AHCCCS applications on all consumers on caseload meeting criteria. Provided transportation to consumer as appropriate and determined by the clinical team. Provided all ACT services to ACT participants as clinically indicated including participating in the assessment and service planning processes; including identifying the need for further or specialty evaluations. Collaborated with the person and his/her family or significant others to implement an effective service plan, explaining the available clinical options to the team, including the advantages and disadvantages of each option. Maintains the person's comprehensive clinical record, including documentation of activities performed as part of the service delivery process (e.g., assessments, provision of services, coordination of care, discharge planning). Provided continuous evaluation of the effectiveness of treatment through the ongoing assessment of the person and input from the person and relevant others resulting in modification to the service plan as necessary. Pursued best practice outcomes for person with mental illness including continuing education, employment, independent housing and community tenure. On-Call duties coverage, as needed.

Residential behavioral health tech ensured the provision of all covered services identified on the services plan; referrals to community resources as appropriate and coordination of care activities related to continuity of care between level of care and across multiple providers, services and supports. Provided outreach and follow-up of services including, but not limited to, crisis and missed appointments to ensure member remained engaged with clinical team and attend all scheduled appointments. Assisted clients with ensuring they remained covered under AHCCCS through portal and provided transportation for clients to clinic appointments. Medication observation, groups and teach independent living skills for members to work towards living in lower level of care. Required documentation to be completed appropriately and accurate to reflect the process of treatment and continued needs for services identified for members to be successful in treatment planning process.