- Persistent and assertive outreach and engagement using strength-based approaches beginning either at known "hang-outs" or "hot spots" within the local communities or during an inpatient hospital admission or emergency department visit.
- Continuously assess the health and social needs of participants through SOS's conversational and observational assessments and formalized risk assessment tools for those identified as being at high risk.
- Participate in hospital discharge planning meetings to identify the best community resources for returning members.
- Assist with appointment navigation including accompaniment to appointments, transportation training, reengagement in community care, and addressing barriers to care.
- Review documentation and conduct comprehensive psychosocial assessments to determine the medical, psychiatric, housing, and other social needs of the member within the community.
- Obtain historical and collateral information from multiple sources to support members' behavioral and physical health needs.
- Monitor, evaluate, and record participants' progress with respect to care plan goals.
- Adheres to Monroe Plan professional boundaries and protocols.
- Work in collaboration with the regional partners to identify available housing and to support participants through the process. Tasks may include applying for housing, prepping for interviews, following up with housing providers, and assistance with moving in (day of move) obtaining housing supplies, and learning about the neighborhood.
- Participate in hospital discharge planning meetings to identify the best community resources for returning members.
- Once housed, work with members and their housing providers to resolve clinical issues that are impacting the member's ability to manage and retain supportive housing.
- Foster relationships with community providers to ensure that members are connected with appropriate services as they transition back into the community.
- Contributes to team effort by accomplishing related results as needed/assigned.
- Regular and predictable attendance is an essential requirement of the job
- Promotes a safety-first attitude by setting a positive example and ensuring all employees are following safety policies and procedures.
- Perform other duties as assigned.
- Minimum High School Diploma or equivalent or higher required.
- NYS Certified Peer Specialist preferred or required completion of an internship or comparable training in peer advocacy required.
- Valid NYS Driver's License in compliance with company policy.
- Collect and report data, as required and work with team leader and other SOS team staff to use data to inform future care delivery.
- Experience in providing advocacy services to people who are mentally ill and/or homeless.
- Must follow CDC guidelines regarding Covid-19, including but not limited to, wearing a mask when working.
- Full vaccination against COVID-19, including Booster (when eligible) is strongly encouraged.
- Cannot perform any tasks which are governed by license or registration (i.e. cannot answer questions or make recommendations regarding diagnosis, medications, or treatment)
- Cannot transport active Monroe Plan members at any time
- Cannot perform hands-on care.
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