Summary of position:
Elder Services aims to support individuals 55+ years of age who are incarcerated by providing jail-based support, discharge planning, and post-release follow-up. Under direction of the Director of Elder Services, the case manager will meet with patients to complete screenings and intakes for the service, as well as engage in follow-up related to patient-indicated areas of need. Each case manager will maintain a case load of patients and meet with those patients throughout their incarceration (regardless of facility).
Responsibilities include:
- Complete screening tools and intake assessments for patients assigned to case load.
o Provide production list to facility HSA; meet with patients in clinic to complete interview and obtain consents.
o Meet with patients in housing area (DOC escorts not provided; staff may travel in pairs/groups; seek support and supervision around patient prioritization and safety)
o Complete document in electronic medical records system (CHER) within 24 hours of encounter; scan and upload relevant consents and documents.
o Escalate any urgent issues to supervisor.
- Complete applications for Medicaid and other benefits programs as appropriate.
o Obtain relevant consents during patient encounter
o Submit applications online using HRA or other platforms.
o Confer with supervisor when needed
- Create individualized discharge plans for each patient according to the patient’s goals and needs and ensure tasks are completed. Tasks may include, but are not limited to: coordinating medical appointments, ensuring medications are called into a pharmacy, making referrals to housing and case-management resources, and confirming transportation between jail and community dwelling is arranged.
o Develop plan with patient; discuss in team rounds and supervision when needed.
o Communicate with community organizations/providers directly, via email or phone; escalating to supervisor when appropriate.
o Review plan with patient prior to discharge, when discharge date is known.
- Provide ongoing in-jail support to patients, meeting with them regularly; frequency to be decided in consultation with Program Director.
o Interventions focus on addressing public health issues that effect the elder populations: homelessness, limited social networks, physical health concerns.
- Serve as conduit between patient and clinical court advocates, and assist as needed with obtaining consents, relaying information, and other tasks.
o Under direction of supervisor, communicate directly with court advocacy team, primarily by email; and/or escalate cases to supervisor.
o Based on needs of court advocacy team, obtain additional information and consents when requested.
- Attend weekly team rounds and participate in patient case conferences with other discharge planning program staff.
o Prepare patients/cases to discuss
o Complete assignments generated from team discussion; follow-up with supervisor
- Conduct post-release follow-up outreach to patients, via telephone, and assist or make additional referrals as appropriate.
o Attempt to contact all patients within 24 hours of release, calling all phone numbers provided on consent.
o Troubleshoot issues (e.g., pharmacy issues, medical appointments, referrals) as able; confer with supervisor as needed.
o Document in CHER.
- Document screening tool, intake assessment, transition plan and collateral information in the electronic health record (CHER).
- Additional tasks and projects as requested by Program Manager and/or Director of Special Populations.