About The Villages Health

The Villages Health is a patient-centered primary care driven, multi-specialty medical group with over 700 team members. Our unique care model gives us both the time and resources to truly care for our patients, along with a company culture that supports a healthy work-life balance for our team members. Our purpose, mission and vision is to empower Villagers and the surrounding communities to live out their dreams by keeping them healthy and healing them quickly. Together, we are changing the way healthcare is delivered and are making a positive difference in the lives of our patients and the communities we serve. In doing so, The Villages Health is creating America’s Healthiest Hometown.

Our Full-time Benefits

Medical, Dental & Vision Insurance | Matching HSA & 401k | PTO & Paid Holidays | The Villages Charter School Eligibility | & much more!

Responsibilities:

This position is responsible for providing direct medical care to patients within the scope of licensing, training, and credentialing. Responsible for helping mentally and emotionally distressed clients adjust to life and may assist medical and surgical patients in dealing with illnesses or injuries in line with clinical practice standards and patient-centered care.

Education/Experience Requirements:

Duties and Responsibilities may include, but are not limited to:

• Identify patients appropriate for Behavioral Health Tandem Care through referrals and collaboration with PCP and Clinical Teams.
• When appropriate, provide 10 sessions evidence-based therapy as per the TVH Behavioral Health Model (if licensed and qualified).
• Act as patient advocate.
• Develops and implements plans for providing treatment of mental illness and preventive services.
• Support the mental and physical health care of patients on an assigned patient caseload. Closely coordinate care with the patient’s medical provider and, when appropriate, other mental health providers.
• Screen and assess patients for common mental health and substance abuse disorders. Facilitate patient engagement and follow up care.
• Provide patient education about common mental health and substance abuse disorders and the available treatment options.
• Systematically track treatment response and monitor patients (in person or by telephone) for changes in clinical symptoms and treatment side effects or complications.
• Support psychotropic medication management as prescribed by medical providers, focusing on treatment adherence monitoring, side effects, and effectiveness of treatment.

• Provide brief behavioral interventions using evidence-based techniques such as behavioral activation, problem-solving treatment, motivational interviewing, or other treatments as appropriate.

• Provide or facilitate in-clinic or outside referrals to evidence-based psychosocial treatments (e.g. problem-solving treatment or behavioral activation) as clinically indicated.

• Participate in regularly scheduled (usually weekly) caseload consultation with the psychiatric consultant and communicate resulting treatment recommendations to the patient’s medical provider. Consultations will focus on patients new to the caseload and those who are not improving as expected under the current treatment plan. Case reviews may be conducted by telephone, video, or in person.

• Track patient follow up and clinical outcomes using a registry. Document in-person and telephone encounters in the registry and use the system to identify and re-engage patients. Registry functions can be accomplished through an EHR build on a spreadsheet used in conjunction with an EHR, or can be built into a stand-alone clinical management tracking system that may or may not be linked to an EHR.

• Document patient progress and treatment recommendations in EHR (in a timely manner) and other required systems so as to be shared with medical providers, psychiatric consultant, and other treating providers.
• Facilitate treatment plan changes for patients who are not improving as expected in consultation with the medical provider and the psychiatric consultant and who may need more intensive or more specialized mental health care.
• Facilitate referrals for clinically indicated services outside of the organization (e.g., social services such as housing assistance, vocational rehabilitation, mental health specialty care, substance abuse treatment).

• Develop and complete relapse prevention self-management plan with patients who have achieved their treatment goals and are soon to be discharged from the caseload.

• Develop and expand the integration of Behavioral Health into the primary care center.
• Attend regular provider meetings, to be defined.
• Participates or provides in-service training to other providers and clinical staff. Provides consultation for mid-level providers and other clinicians.
• May serve as preceptor to residents and students.
• Maintains confidentiality of patient care and organizational operations at all times.
• Assists Behavioral Health Medical Director / Program Manager in the development and updating of policies, guidelines, and medical orders used in the delivery of mental health care to patients.
• Other duties as assigned.

Salary is commensurate with experience.