Fallon Health operates the largest Program of All-Inclusive Care for the Elderly (PACE) in New England and the fifth largest in the country. Called Summit ElderCare, Fallon’s PACE helps provide older adults and their caregivers with a welcome alternative to nursing home care. Participants in Summit ElderCare have access to comprehensive medical services and social support at a Summit ElderCare site while they keep the independence of living in their own homes and communities.

• Provides behavioral health support to Summit participants as referred by the IDT:
  • Conducts psychosocial, behavioral screenings and assessments of program participants and writes professional reports in the EMR
  • Participates in the development of an interdisciplinary treatment plan appropriate to participant’s goals and level of functioning, mental health or cognitive status, and care needs.
  • Makes recommendations for appropriate treatment to community MH specialists.
  • Collaborates with Community MH specialists in sharing appropriate information to support the most effective care for individual PACE participants.
  • Provides direct BH treatment as appropriate via individual counseling/coaching, and facilitates psychotherapeutic and psychoeducational groups within the evidence-based, integrated primary care protocols of the Summit Eldercare BH program.
• Acts as consultant to the IDT and primary care team in supporting participant behavior change, recommending interventions and collaborating with team members in family meetings, discharge planning meetings and care planning, Reviewing service requests and re-authorizations for community-based specialty mental health services:
  • Participates in IDT meetings
  • Facilitates BH Rounds
  • Provides impromptu “curb-side” consultation with team members
  • Attends acute-care or rehab discharge planning meetings as needed
  • Attends care planning meetings as needed and makes BH recommendations for inclusion in the PACE care plan
  • Develops and implements psychosocial interventions appropriate to primary care settings.
  • Receives and reviews updates from community-based psychotherapists for medical necessity
  • Makes recommendations to the IDT regarding appropriateness of initial referrals to psychotherapy and on progress of ongoing psychotherapy
  • Facilitates case referrals for team consultation to Summit psychiatry consult program
• Provides education and training:
  • Conducts trainings on BH topics and skills related to PACE population in general and site-specific population for SE personnel within the paradigm of Summit Eldercare BH program.
  • Provides education to IDT members and other staff related to specific participants’ BH needs and general BH principles.
• Evaluates and provides support to caregivers to improve care giving:
  • Meets with family caregivers as needed to support participant care
  • Participates in family meetings when requested or otherwise appropriate

• LMHC, LMFT, Licensed Psychologist or LICSW

• Experience in providing behavioral health services in outpatient primary care medical office or similar healthcare settings helpful.
• At least one year of experience working with older adults.
• Experience with Cognitive-Behavioral, Motivational Interviewing, Solution-Focused, Transtheoretical, and InterPersonal Theory techniques for promoting behavior change.
• Understanding of the physiological, psychological and neuropsychological contributors to behavior in diverse clinical population.
• Ability to use clinical judgment to provide appropriate and effective treatment
• Ability to diplomatically maintain client confidentiality and HIPPA standards when including family members and caregivers in discussions or consults
• Able to work as a team member.

• Access to reliable transportation to carry out community assignments is required

• Excellent written and verbal communication skills
• Excellent organization and time management skills and ability to complete record-keeping in a timely manner required.
• Facile with computer applications including an Electronic Medical Record.