- Provide care based on the needs of the assigned Care Pod and customize treatment plans to individual patients.
- Coordinate behavioral health care with patients’ primary care providers and, when appropriate, other service providers.
- Screen patients for behavioral health and substance use disorders using tools such as PHQ9, GAD7, and the Columbia Suicide Risk Assessment.
- Monitor clinical symptoms, treatment side effects, and complications, with the goal of reducing symptoms.
- Support psychotropic medication management prescribed by primary care providers, including adherence, side effects, and treatment effectiveness.
- Track follow-up and clinical outcomes in the registry, record encounters, and identify and re-engage patients.
- Develop self-management goals and interventions with patients and facilitate care plan changes or referrals when patients are not improving.
- Document patient progress and treatment recommendations in Salesforce and the electronic health record.
- Educate patients about behavioral health and substance use disorders and treatment options, and complete relapse prevention plans for patients in remission.
- Coordinate care plans with patients, families, and the care team; participate in caseload consultations and supervision; and work with Care Navigation Partners to address social determinant barriers.
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