Title:                    Patient Problem Solving Specialist
 
Program:             CES Adults - Single
 
Reports to:          Program Director
 
Valley Oasis Coordinated Entry System provides comprehensive services designed to address the root cause of poverty and homelessness within SPA 1 of Los Angeles County. Participants may be mentally ill, have intellectual developmental disabilities, substance abuse issues, and chronic medical/physical disabilities, exiting institutions and are homeless.

The Patient Problem-Solving Specialist (PPSS) aims to connect discharged patients who are experiencing or at risk of homelessness with resources that can end their housing crisis, including potential resources via CES. The PPSS must attempt the Problem-Solving Intervention with households prior to connecting to CES resources. The primary goal of the PPSS is to increase linkages between hospitals, clinics, and homeless services. The goal is that the PPSS improves referral processes, increases communication across systems, and increases partnership opportunities to expand housing resources for patients experiencing homelessness. 

Essential Job Functions:

• Act as the initial point of contact for individuals age 18 and over experiencing homelessness
• Assist discharged patients experiencing or at-risk of homelessness with accessing social support networks, mainstream, or CES resources to end their housing crisis
• Work with patients currently unhoused or at risk of being unhoused referred by hospitals and clinics by conducting PS conversations and referral to CES resources only PS is not possible
• Must respond to referrals in the Hospital Referral Portal in less than 72 hours
• Using a collaborative, participant-centric, strengths-based, trauma-informed approach and a range of services, services techniques (such as mediation) and short-term assistance, support families in avoiding entry to shelter or the experience of street homelessness (e.g. helping those seeking services to safely remaining in their current living situation, or identify immediate alternate, safe housing arrangements)
• Screen and engage in problem solving intervention with adult individuals and/or their partners in the household
• Engage with patients over the phone, or virtually, and provide resources or referrals in-person, by phone, or virtually
• Embed Problem-Solving Intervention strategies into the initial screening, explore for social supports, make emergency service referrals, make warm handoff referrals, make supportive service referrals, and deliver support based on the needs and preferences of the participant
• Utilize the Patient Referral Portal (PRP) to receive, track and maintain referrals from hospitals and clinics
• Ensure all local partners are aware of, trained in use of, and have access to, the PRP
• Track each Problem-Solving conversation on the Problem-Solving Tracking Tool on the Homeless Management Information System (HMIS)
• Analyze information, problems, situations, practices or procedures in order to define the issues/challenges, relevant factors or concerns to accomplish success.
• Recognizing each service seeker’s unique strengths, support youth to look for creative solutions that can be quickly implemented.
• Must be able to problem solve a variety of complex issues, and always maintain a high level of professionalism while doing so.
• Implement immediate crisis housing plan, including diversion to family and friends, placement in a shelter or interim housing, linkage to permanent housing, and/or alternative housing resources
• Engage in deliberate thoughtful and individualized conversation(s) that seek to solve the individuals immediate and/or near-term housing crisis
• Utilize active listening, coaching, motivational interviewing, mediation, and conflict resolution with families/friends and/or Landlords, connection to mainstream resources, housing search assistance, housing stabilization planning, and relocation
• Negotiate when appropriate with family, friends, and landlords to keep individuals from entering the homeless system
• Connect individuals to supportive services such as health, mental health, mainstream benefits, education, and vocational assistance.
• Connect participants with appropriate partner agencies through referrals and follow-up to ensure connections were made.
• Responsible for case conferencing with medical social workers and ongoing staff, fostering ongoing mutual learning, and is to remain up to date on mutual objectives, eligible referrals, and system awareness
• Provide referrals to emergency services if requested or needed by participants. Emergency services, in this instance, included crisis housing, drop-in centers, and emergency services available for survivors of domestic violence, human trafficking, and sexual assault
• Provide a warm hand-off referral to the Access Center in the SPA serving that population if Problem-Solving outcome is not identified. Referral should be to the service planning area (SPA) the participant has ties in, not necessarily the community of the hospital. 
• Provide crisis intervention assistance as needed.
• Based on the information collected during the assessment process and using the HMIS System and CES protocol, make authorized, prioritized referrals into housing programs and CES Housing Navigation services.
• Conduct immediate and longer-term follow up to ascertain the effectiveness of problem-solving activities.
• Track and report progress and services for each participant receiving problem-solving assistance and the project as a whole.
• Develop and maintain a complete, accurate, and current file with all required documents and data in agency records and electronic database, HMIS. Includes updates to changes in income and any demographic domain. Maintain confidentiality of participant files per HIPAA and all applicable guidelines
• Document services provided within 24 hours
• Draft monthly reports on service numbers, participants served, and achievements as well as other pertinent quantitative outcomes to Supervisor, and other executive staff and Coordinated Entry external partners as requested.
• Provide professional, accessible and culturally relevant support, advocacy and information to program participants.
• Work within and promote the integrated services team model in an environment dedicated to harm reduction, recovery and wellness.
• Engage effectively and constructively with Supervisor to make program refinements in the best interests of service users
• Ensure services to participants are reflective of customer choice and emphasize housing first, harm reduction and trauma-informed care models
• Use effective communication skills such as active and reflective listening to build rapport. Utilize appropriate motivational interviewing interventions to increase positive outcomes
• Liaise with other providers within the agency, as well as outside to formulate strength-based strategies that focus on housing retention and general wellness
• Participate in LAHSA meetings and trainings as requested to improve Problem-Solving skills and best support the relationship and referrals between medical institutions and the homeless services system. 
• Participate in staff meetings, individual and group supervision, case conferences and training as required
• Adhere to agency policies and procedures including confidentiality, child abuse reporting, and code of ethics
• Additional tasks, projects and or responsibilities as assigned by Supervisor that are not outlined but which are an important part of the agency’s goals and/or program outcomes

Knowledge, Skills & Abilities:

• Clear understanding of the concepts of Housing First, Harm Reduction, Trauma Informed Care, Motivational Interviewing, and the Coordinated Entry System
• Knowledge and understanding of policy, systems, and local programs that impact homeless persons and related public funding sources, regulations, requirements, and procedures
• Knowledge of resources including legal, medical, housing, educational and social service agencies and other resources in the community
• Knowledge of best practice models for assisting homeless people with varying degrees of needs/conditions and have a strong understanding of contractual requirements/compliance and applicable performance measures
• Knowledge of issues facing homeless individuals (e.g. chronic health, substance abuse, mental health, domestic abuse and resources for undocumented individuals)
• Strong knowledge/experience working with individuals in crisis or unstable housing situations
• Strong knowledge of issues confronted by and sensitivity to individuals with substance abuse, domestic violence, HIV/AIDS, mental health issues, history of trauma and co-occurring-diagnoses
• Knowledge of community social service agencies and resources
• Work effectively under conditions of limited supervision, high stress and rapidly changing situations and circumstances
• Ability to handle common problems without supervisor intervention while knowing when supervisor participation is warranted
• Must be able to exercise initiative, independent good judgment, flexibility, discretion, and solid decision making
• Ability to respond quickly and effectively to individuals who may be ill, using substances, lack of personal care, in crisis situations and/or potentially hostile situations
• Able to take appropriate steps to deal with emergency situations with the goal of maintaining the safety of all participants
• Ability to work with a diverse population and provide culturally competent advocacy
• Ability to deescalate aggressive/agitated individuals
• Actively promote positive, nurturing interactions between participants
• Must be able to successfully manage multiple priorities, meet deadlines, adjust to changing; circumstances, and demonstrate confidence working with diverse stakeholders
• Demonstrate the ability to utilize strong judgement and interpersonal skills to manage sensitive participant interactions including with those who may be in distress with acute illness, substance use issues, co-morbidity of behavioral and physical health issues in addition to homelessness
• Project a professional demeanor and a high level of professionalism when dealing with sensitive matters
• Promote cooperation and commitment within a team to achieve goals and objective; collaborate with team members, sharing ideas and differences openly; be receptive to new ideas and adapt to change as necessary
• Considers impact of personal and professional choices. Consistently make decisions in keeping with organizational values and Supervisor’s direction
• Strict confidentiality must be observed as it relates to participant information, agency business, program decisions and all other personal information
• Excellent organizational skills and the ability to follow through from beginning to end on tasks
• Outstanding communication skills, both written and oral; must communicate professionally and positively with participants, co-workers, management, community partners, employers, landlords, and other service providers
• Proficient with office communication equipment and machines (telephone, copier, calculator, fax machine, personal computer, laptop, computer printer and scanner).
• Proficient in use of laptop/desktop computer, Microsoft Windows and Office software programs (Word, Excel, and PowerPoint) and Google drive
• Strong time management skills and the ability to multi-task and prioritize in a fast-paced environment, while exercising sound judgment.
• Able to work a flexible schedule; including nights, days, weekends and holidays when needed
• Able to respond to emergencies some evenings and weekends as necessary
• Use of a personal vehicle may be required to travel in and around Antelope Valley and/or Los Angeles County and periodically transport participants
• Maintain professional boundaries and work collaboratively with participants, volunteers and staff
• Accountability – be on time for scheduled shifts
• Be able to read and write English
• Bilingual Preferred but not required

Qualifications & Experience:

• High School Graduate or equivalent
• Bachelor’s Degree in Social/Human Services or related field, strongly preferred
• One year experience in case management for homeless individuals
• Experience in social services field; preferably working with homeless programs in a non-profit setting
• Experience with Homeless Management Information System (HMIS)
• Education may be substituted by years of experience

Agency Requirements:

• Must have a valid California Driver’s License
• Clean driving record
• Reliable transportation
• Auto Insurance

Physical Demands & Work Conditions
 
An employee to successfully perform the essential functions of the job must meet physical demands described:

• May be in contact with individuals in crisis who may be ill, using substances and/or not be attentive to personal hygiene and safety for themselves
• May experience unpleasant sensory demands associated with an individual’s use of alcohol and drugs, and lack of personal care
• May experience crises and potentially hostile situations, must be ready to respond quickly and effectively.

An employee is required to:

Walk and climb stairs; Handle, grasp and feel objects and equipment; Reach with hands and arms; extend both arms above the head and/or reach below the waist; Communicate ideas and information verbally and written word; Be able to move oneself quickly and easily from place to place; Repeat various motions with hands, wrists, fingers; Climb on stools, steps and/or ladders; Be subject to outside environmental conditions, including but not limited to: Rain, heat, wind; lift at least 10 lbs 
Reasonable accommodations may be made to enable individuals with disabilities to perform the essential job functions. If accommodation(s) are required, employee must inform Human Resources by the first week of employment. If an accommodation is not required at the time of employment, but is later required, you must inform Human Resources at the time it is needed.
 
Benefits

Health	Employee Assistance Plan	Paid Sick
Dental	AFLAC	Paid Vacation
Vision	Cafeteria 125 Plan	Personal Days
Acupuncture/Chiropractic	Retirement Plan
Life Insurance	14 Observed Holidays

 
Schedule:
Monday – Friday 8am – 5pm (may be required to work other than normal duty hours, to include evenings, weekends, holidays and/or on call status)

Salary Range
$24.00 - $26.00 per hour
 
An Equal Opportunity Employer: Selection will be based solely on merit and will be without discrimination because of age, race, sex, religion, national origin, marital status, sexual orientation, mental or physical disability.
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