The Family Support Specialist/Health, with the knowledge of the building Principals, is responsible for identifying and enrolling students within their assigned school building, who meet the eligibility requirements for New York State’s Children’s Health Home program. The FSS/H will work directly with students and families who are experiencing difficulties with medical/behavioral or other social-emotional issues. FSS/H will work with a family to address social determinants of health which may be a barrier to school engagement and academic success. The FSS/H plan of care will include one or more of the following elements: care management, care coordination and health promotion, transitional care and family supports.

The Family Support Specialist position compliments existing BPS School Support Teams and will not reduce, interfere with, or perform services provided by any BPS employees. The function of the Family Support Specialist role is to provide services and supports to those students that have been referred by school personnel, (e.g., Student Support Team members, school counselors, attendance teachers, social workers and administrators). The function of the FSS/H role is to reduce utilization associated with avoidable and preventable inpatient hospital stays, to reduce overutilization of emergency room visits and to improve academic and well-being outcomes for BPS students. HH eligibility is based on a member having two chronic conditions as diagnosed by a licensed professional and is the equivalent of a Tier 3 level of need.

Major Responsibilities/Tasks

• Work directly with eligible students as referred by BPS Student Support Teams (SST)
• Collaborate with building Administrators, School Nurses, SST, and Community School Navigators to identify students who are Medicaid eligible and otherwise eligible for HH services
• Participate in on-site collaboration, facilitation and enrollment of referred students and families with identified service providers including satellite mental health clinics, in-school legal and health services, after school providers and other identified services
• Participate in relevant school management team meetings (PBIS mtgs.)
• Document all case specific activities, including outreach, assessment, plan of care development, student progress, home and family visits
• FSS/H will engage students during the school day but will also engage families in the home and outside of normal school hours as needed
• Administer CANS-NY as a comprehensive assessment tool to determine acuity of care needed
• Develop a comprehensive student-centered health assessment inclusive of medical, behavioral and social service needs
• Conduct case conferences with multidisciplinary team members including primary care physician to assure changes in medical/behavioral conditions and treatment are appropriately addressed
• Link and refer students to needed services to support care plan/treatment goals
• Serve as liaison between service providers and school building staff and administration, including informing school staff regarding the Say Yes services and programs offered in the building and how to refer students and families
• FSS/H will participate in community events including community resource fairs and other outreach events with some non-traditional hours required
• Work with building administrators to implement tasks related to the Say Yes Student Management System (PPS) for students, parents, and teachers, including questions related to survey completion and how to access individual student growth plans and data driven interventions and outcomes

Minimum Qualifications:

• Bachelor’s Degree in Social Work or related field, MSW preferred
• Three (3) years of experience in the Social Work field
• Health Home experience preferred but not required
• Valid NYS Driver's License
• Believe and practice Say Yes Racial Equity Statement, “Equity will be achieved when we can all just wake up and live freely; be valued and respected; live free from structural impediments based off of perceived racial characteristics; and, have fair representation and opportunity.”