- Provides care to patients, based on needs of assigned Care Pod, customizing treatment plan to individual patient needs
- Supports and closely coordinates behavioral health care with the patient’s primary care provider and (when appropriate) other service providers
- Screens patients for common behavioral health and substance use disorders using PHQ9, GAD7, Columbia Suicide Risk Assessment, or other tools as required
- Monitors patients for changes in clinical symptoms and treatment side effects/complications
- Supports psychotropic medication management prescribed by PCPs, focusing on treatment adherence, side effects and treatment effectiveness
- Tracks patient follow-up and clinical outcomes using a registry
- Documents patient progress and treatment recommendations in Salesforce and the electronic health record
- Facilitates care plan changes for patients who are not improving
- Identifies social determinant barriers and works alongside the Care Navigation Partner
SalesforceEHR