Aftercare Specialist

Description

As a member of the treatment team, the Aftercare Specialist assumes a central role in ensuring community-based services and supports are available for all consumers beginning at admissions and up to ninety days (90) post discharge. S/he works directly with consumers in individual and group sessions on issues surrounding discharge planning, identifying community-based supports and securing appropriate living arrangements. The Aftercare Specialist will maintain contact with discharged consumers for ninety (90) days post-discharge to ensure continuity of care as it relates to mental health services, substance use disorder services, primary healthcare, vocational and other critical support services.

· Responsible for ongoing consumer discharge planning including the development of a formal discharge plan.

· Monitor and evaluate consumer needs, including prevention, wellness, medical, mental health, care transitions, and social and community services where appropriate.

· Maintain up-to-date consumer charts including referrals and outcomes.

· Support adherence to treatment plan recommendations.

· Link consumers to instrumental support services such as Medicaid, Medicare, Social Security, food stamps, home health care, Health Home Programs, Senior Citizen Rent Increase Exemption (SCRIE) and home delivered meals prior to discharge.

· Link consumers to psychosocial/healthcare support services (e.g. SUD recovery supports, aftercare, mental health, primary care, social adult day services, vocational/educational services, etc.) prior to discharge.

· Develop and facilitate Independent Living Skills workshops to build skills and increase knowledge related to activities of daily living, ability to access community-based resources, spending habits and money management.

· Attend regularly scheduled staff meetings and case conferences.

· Attend all required in-service training seminars.

· Maintain accurate client data including tracking consumers ninety (90) days post-discharge.

· Participate in quality improvement activities.

· Other relevant duties as assigned.

 PM20 

Requirements

Bachelor’s Degree or Associate’s Degree with two (2) years of related experience in health insurance, care coordination, entitlement, or housing placement services for low income and/or homeless populations.

· Experience providing service coordination and information, linkages, and referrals for community-based services.

· Knowledge of city, state, and federal guidelines for public and private low-income housing, entitlements and health insurance.

· Ability to research and network with other agencies/community-based services to meet a variety of client needs.

· Proficiency with computer operation (Microsoft Word, Excel, AWARDS, and Outlook programs).

· Excellent written and verbal communications skills.

· Bilingual English/Spanish a plus

· Must be able to work a flexible schedule.

· This position requires regular travel throughout the five (5) boroughs.