Behavioral Health & Home Visiting Community Health Worker FAQ

Behavioral Health Counselors (BHC) Team

• 4^th St

• Mariella Roberts, LPCMH

• Kathleen Seipel, LCSW

• Newark-Evelyn Cruz, LPCMH

• Bear-Maria (Maricarmen) Martinez-Martinez, LPCMH

• Remote-Lydia De Leon, LPCMH, Director of Behavioral Health

What we do:

• Behavioral Health Counseling services: (billable)

• Short-term counseling services

• For established patients of all ages (children, adolescents, and adults)

• 30-minute sessions, 9-12 sessions, focused on self-management goals

• All Counselors are bilingual in English and Spanish

• Generalists using evidence-based treatment modalities to treat behavioral, mental, and substance abuse problems

• Recommendations and referrals to higher level of care and BH specialty treatment as needed

• To refer patients to counseling services, please send an EMR Counseling referral

• Patients can speak with a Behavioral Health Counselor by calling (302) 607-2350

• Behavioral Health Integration services: (non-billable)

• Consultations and collaborations with the primary care team to enhance the patient’s outcome and experience in treatment warm-handoffs, brief interventions, the intro of services, and crisis interventions

• these services are free of charge to patients

• available Mon, Tues, Wed, and Fri-8a-5pm; Thursdays 8am-12pm

• To utilize these services, please send a message to the Behavioral Health Team via Teams and any available BHC/SSCM team will respond to assist.

• Patients can speak with a Behavioral Health Counselor Monday-Friday

  8 am-5 pm by calling (302) 607-2350.

Important things to remember:

• Counselors are not prescribers- send Med eval/management EMR referral

• Counselors are not able to complete psychological testing-send EMR referral to the Social Services pool to connect patients to community resources.

• ***Please use the BH Credentialing Smartsheet when scheduling counseling appointments with the BHC team and meds management appointments with the Psych NP team. Refer to the Social Services Pool when we are not credentialed with the patient’s insurance. This does not apply to appts with the Social Services team. SS appointments are always free of charge for our patients.

Psychiatric Nurse Practitioners (Psych NP) Team:

• Kiley Gilbert, PMHNP-BC: Telehealth only, Mondays-Thursdays, 10 am-6 pm

What we do:

• psychiatric assessments, diagnosis, evaluations, and management of psychotropic medications (billable)

• services available for established patients of all ages-children, adolescents, and adults

• consultations, recommendations, and collaborations with the primary care team to enhance the patient’s outcome and experience in treatment (non-billable)

• available Mondays through Thursdays via EMR or via Teams

• To refer patients to counseling services, please send an EMR Counseling referral

Important things to remember:

• Psych NPs are not counselors/therapists- send EMR counseling referral

• Psych NPs are not able to complete psychological testing-send EMR referrals to the Social Services pool to connect patients to community resources.

• ***Please use the BH Credentialing Smartsheet when scheduling counseling appointments with the BHC team and meds management appointments with the Psych NP team. Refer to the Social Services Pool when we are not credentialed with the patient’s insurance. This does not apply to appts with the Social Services team. SS appointments are always free of charge for our patients.

Social Services Case Managers (SSCM) Team

• 4^th St & NE-Denise West

• Bear & Newark-Emily Barnes

• Dover-Elika Mercado

• Manager of Social Services-Eunice Holman

What we do: (non-billable)

• Screen and connect all established patients and families to appropriate internal services and community resources that will help address Social Determinants of Health.

• Support behavioral health integration by providing quick intervention and crisis intervention.

• Manage behavioral health referrals and provide case management connecting patients to the appropriate level of care for mental health and substance use disorder.

• All social services are free of charge to patients

Referrals that the team does not work with:

• Standard MEDICAID-refer to Enrollment Specialist team

• WIC-refer to Breastfeeding Peer Counselors team

• Financial Assistance: Christiana Application-refer patient to contact CCHS Health Guides

• Abortion Resources-refer to PCP/Nurses team

• MAP (Medication Assistance Programs) -refer to Enrollment Specialist team

• Social needs for non-patients-please send an EMR message to the Community Health Workers pool

Referral Process:

• Non-urgent matters, please send all referrals to the Social Services EMR pool.

• Use the Social Services Teams group for urgent matters. If, for any reason, a response is not received, proceed by sending an URGENT message on EMR.

• If you have a BH need or crisis: use the Behavioral Health Teams group.

• Patients can call (302) 607-2360 for social services Monday-Friday 8 am-5 pm

Community Health Workers (CHW) Team

• Sarah Ocampo: 4^th St. - New Castle County

• Manager of Social Services-Eunice Holman

What we do: (non-billable)

• Screen and connect patients and community members to community resources that will help address Social Determinants of Health.

• Able to meet with patients and community members out in the community to help address Social Determinants of Health.

• Participate in community outreach and public education by attending community events and conducting presentations in the community.

• All Community Health Workers Services are free of charge to patients and community members.

Referrals that the team does not work with:

• Standard MEDICAID-refer to Enrollment Specialist team

• WIC-refer to Breastfeeding Peer Counselors team

• Financial Assistance: Christiana Application-refer patient to contact CCHS Health Guides

• Abortion Resources-refer to PCP/Nurses team

• MAP (Medication Assistance Programs) -refer to Enrollment Specialist team

• For behavioral health referrals and Case Management Referrals, please refer to the Social Services Pool on EMR.

Referral Process:

• Non-urgent matters, please send all referrals to the Community Health Workers EMR pool.

• Use the Community Health Workers group for urgent matters. If, for any reason, a response is not received, proceed by sending an URGENT message on EMR.

• Patients can call (302) 225-1805 for Community Health Workers Monday-Friday

  8 am-5 pm

Home Visiting Community Health Workers (HV-CHW) Team

• Lynn Mann: 4^th St New Castle County/Kent County

• Manager of Social Services-Eunice Holman

What we do: (non-billable)

• Service referrals to home visiting services, and case management to patients and members of the community.

• Participate in community outreach and public education by attending community events and conducting presentations in the community.

• Provide education and resources to patients and members of the community to reduce maternal health disparities and improve infant health. HV-CHW provides health promotion information during the stages of prenatal and up to 5 years of age.

• Screen patients/Community Members for Car Seat Programs & Pack & Plays.

Referrals that the team does not work with:

• Standard MEDICAID-refer to Enrollment Specialist team

• WIC-refer to Breastfeeding Peer Counselors team

• Financial Assistance: Christiana Application-refer patient to contact CCHS Health Guides

• Abortion Resources-refer to PCP/Nurses team

• MAP (Medication Assistance Programs) -refer to Enrollment Specialist team

• For behavioral health referrals and Case Management Referrals, please refer to the Social Services Pool on EMR.

• For non-prenatal referrals and individuals aged 5 and older needing SDOH resources, please consult the Community Health Workers pool in the EMR.

Referral Process:

• Non-urgent matters, please send all referrals to the Community Health Worker EMR pool.

• Use the Community Health Workers group for urgent matters. If, for any reason, a response is not received, proceed by sending an URGENT message on EMR.

• Patients and community members can call (302) 678-4622 Ext.1836 or 302-632-1395 for a Home Visiting Community Health Worker Monday-Friday 8 am-5 pm