Job Description

Job Description

Job Description

Job Title: Community Outreach Advocate – Crossroads

Summary:

Under the direction of the Clinical Operations Department, the Community Outreach Advocate (COA)-Crossroads will work in collaboration with the primary care team responsible for patients experiencing homelessness.

The population is inclusive of people living with multiple complex unmanaged/undermanaged chronic conditions, mental health conditions, substance misuse disorders, trauma history, multiple barriers to adherence, low health literacy, and high social determinant of health barriers with the goal of improving health equity for our patients and improve their ability to self-manage their health.

Outreach includes, but not limited to, facility visits, clinic visits, community visits, home visits, telephonic outreach, and HIPAA compliant virtual meetings. This requires off site travel throughout RI. The COA – Crossroads will support the patient to address social determinants of health (i.e. food, housing, transportation) barriers by identifying and connecting patients with the appropriate resources in the community, as well as assisting patients with any care coordination and data collection. Collaboration with other disciplines and services within PCHC is essential in the support of a patient centered plan of care. Additional collaborations can include, but are not limited to, health specialists, community agencies & resources, external case management supports, and schools.

Essential Duties & Responsibilities: include the following: other duties may be assigned

• Independently prioritize workload and outreach
• Work independently to maintain timely, accurate records, documentation
• Balance new referrals and actively engaged patients to stay within outreach timelines
• Assess patient/caregiver social determinant of health need through SDOH screening tools
• Assess depth of SDOH need based off assessment specific to the identified need; evaluate other SDOH needs that may not have been originally detected by the referral source
• Identify patient/caregiver barriers to health equity/access to appropriate care/adherence to provider recommended care
• Educate patient on COA services and assess the patient’s willingness to engage
• Utilize critical thinking to ensure referrals to and/or collaboration with the appropriate clinical team members occurs in a timely fashion
• Develop a culturally appropriate patient-centered plan of care that includes SMART goals
• Complete appropriate timely follow-up and care coordination within timeline expectations and in accordance with the plan of care
• Maintain an active caseload that includes patients/caregivers requiring ongoing support to reach goals
• Maintain detailed records related to patient engagement, collaboration, and coordination activities in the electronic health record
• Assess patient/caregiver knowledge and barriers to facilitate transitions of care from facility to home/community setting; connecting to appropriate resources and/or clinical supports to reduce readmissions and avoid ambulatory condition ER visits
• Complete and document medication history using patient/caregiver responses and PCHC approved tools
• Complete screenings per program requirements (i.e. PHQ, CAGE, GAD, HRA, SDOH, etc.)
• Support chronic condition management with PCHC protocols related to, but not limited to, diabetes, cardiovascular, and/or asthma checklists
• May be required to cross over COAs in other roles in the organization

QUALIFICATIONS To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Education/Certifications

• Associates degree in Social Work, Human Services, or Community Health/Health Promotion, plus 2 to 3 years’ related experience is required. Bachelors degree preferred.
• Prior experience as a Certified Community Health Worker (CCHW) Accreditation is preferred. Certification required within 18 months of hire.

Required

• Must possess exceptional critical thinking skills and excellent decision making skills. Must be able discern between multiple factors and know when to escalate situations to one’s manager. Keenly aware of clinical policies effecting patient care.
• Bilingual; proficient in spoken and written English and Spanish language required- language proficiency test required. Trilingual skills including Spanish preferred.
• Valid driver’s license with reliable transportation and proof of minimum auto insurance required
• Effective communication skills and ability to engage patients/caregivers in their plan of care
• Ability to work independently and collaboratively
• Demonstrated cultural competency of the community served

Preferred

• Resident in community for two years with knowledge of local community resources
• Lived experience(s) that align with the PCHC population being supported
• Knowledge of Medicaid and Medicare
• Knowledge of value-based care

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