Kirstin Care Health Home Assistant

Kirstin Care Health Home is a growing outpatient and community mental health program

that is operating in the Maryland area. The services provided are comprehensive care

management, care coordination, health promotion, comprehensive transitional care,

individual & family support service, and referrals to external services. Services are

offered for adults and children starting from age 5-65 and are offered in the office and

the consumer’s household.

Education: Associates Degree, Bachelor’s Degree, Master’s Degree

This is a part-time position

Responsibilities:

• The intern will assist the health home nurse and admin team with comprehensive assessment of preliminary service needs, including screening for co-occurring behavioral and somatic health needs
• The intern will assist the health home nurse and admin team with development of consumer-centered care plan
• The intern will assist the health home nurse and admin team with development of treatment guidelines
• The intern will assist the health home nurse and admin team with monitoring of individual and population health status and service use to determine adherence to treatment guidelines
• The intern will assist the health home nurse and admin team with reporting of progress toward outcomes for consumer satisfaction, health status, service delivery, and costs
• The intern will assist the health home nurse and admin team with implementation of the consumer-centered care plan, including appointment scheduling
• The intern will assist the health home nurse and admin team with conducting referrals and follow-up monitoring, including long-term services and peer-based support;
• The intern will assist the health home nurse and admin team with participating in hospital discharge processes communicating with other providers and consumers/family members, as appropriate.
• The intern will assist the health home nurse and admin team with health education, specific to chronic conditions
• The intern will assist the health home nurse and admin team with development and follow-up of self-management plans emphasizing person-centered empowerment
• The intern will assist the health home nurse and admin team with education regarding immunizations and screenings
• The intern will assist the health home nurse and admin team with health promoting lifestyle interventions, such as: – Substance use prevention – Tobacco prevention and cessation; – Nutritional counseling, obesity reduction and prevention; and – Physical activity.
• The intern will assist the health home nurse and admin team with comprehensive transitional care services aim to:
• Streamline plans of care ease the transition to long-term services and supports
• Reduce hospital admissions and interrupt patterns of frequent hospital emergency department use.

The Health Home Team will:

• Collaborate with clinical, therapeutic, rehabilitative, and other providers to implement the treatment plan;
• Increase consumers’ and family members’ ability to manage care and live safely in the community; and
• Emphasize proactive health promotion and self-management.

Description of the program:

Health Home offers enhanced services and supports for participants with serious mental

health issues, emotional disturbance, and opioid substance use disorders. The

complexity of managing these conditions often increases the challenges of treating and

preventing additional chronic health issues, both behavioral and somatic. Those with

behavioral health conditions face unique barriers in addressing their physical health

needs, resulting in disproportionately poor health outcomes, low engagement in

preventive health efforts, and high rates of avoidable hospital and emergency

department (ED)encounters. Health Home assists participants of all ages in improving

overall wellness through a whole-person approach to addressing their behavioral,

somatic, and social needs. Becoming a Health Home allows behavioral health providers

to augment their existing services, building upon and adding to their staff and activities

to better serve participants. This is accomplished through connecting participants and

caregivers to the myriad of supports and services available to them, offering health

promotion activities, monitoring both somatic and behavioral health needs, and assisting

with transitional care. The Health Home becomes the locus of care, building

participants’ self-management capacity while reducing avoidable hospital usage and

ultimately improving outcomes.

Like adults with serious mental illness, children and adolescents with serious emotional

disturbance face an elevated risk of adverse health consequences. While all Health Homes aim to reduce these negative outcomes, those serving children

emphasize coordinated prevention, health promotion, and wellness activities that focus

on their health-related choices and behaviors. These efforts involve augmenting the existing

services provided to children with SED through not only the somatic and behavioral

health care systems, but also through local school systems, the child welfare and

juvenile justice authorities when applicable, and other child and family service providers

as appropriate.

Job Type: Part-time