Job Description

The Centers for Medicare and Medicaid Services developed a health care program to better support patients and families suffering with dementia. The program is called GUIDE, this position supports this new program, and is intended to play a liaison role between health care and the local community.

Major Responsibilities:

Patient Outreach & Resource Navigation

• Provide intensive outreach efforts by conducting home visits or visits to other appropriate settings to an identified patient population.
• Establish relationships with patients/families and provide general support and encouragement.
• Conduct intake interviews with patients using established protocols and intake tools.
  Work with patients and their physicians to develop personal health action plans that are achievable.
• Assist patients in addressing challenges to care for transportation, language, family/social support.
• Assist patients with comprehension of health insurance eligibility, benefits and navigation.
  Schedule appointments and perform reminders for patients. Ensure appropriate resources are available for attending appointments.
• Follow-up with patients by letter, phone call, text or home visit on missed appointments or referrals.
• Educate patients on self-care, healthful living, setting and achieving goals, using/reinforcing SUHI’s clinical education protocols, APP’s evidence-based tools or other, evidence-based tools.
• Refer patients to community-based resources to adhere to physician recommendations.
• Alert APP clinical team on patient needs, concerns, and interests. Ensure continuity of care.
• Keep accurate records of patient contacts and document patient needs, action plans, and follow up needs in appropriate database or electronic medical record.
  
  
  
  Health Education
• Provide health education activities for identified health concerns such as Asthma, Diabetes, Hypertension and other chronic diseases.
• Provide informal counseling, education, and social support to assist patients with gaining access to continuous care and enabling services.
• Coach/encourage patient self-management and adherence to clinical recommendations for identified health concerns such as Asthma, Diabetes, Hypertension and other chronic diseases.
  
  
  
  Community Outreach & Advocacy
• Develop and maintain strong working relationships with external (e.g., referral sources and community agencies) and internal contacts (care team) through direct contact including participating in community meetings and care team huddles.
• Share information and resources, collaborate on initiatives and provide education to referral sources and community agencies to coordinate access to services.
• Collect and organize information to be used for current services and future community health education and outreach activities.
  
  
  
  Program & Care Team Operations
• Participate in care team huddles to understand and proactively respond to the needs of the patient population.
• In collaboration with the clinical team, identify, consolidate and manage a high-risk patient registry.
• Assist care team as needed and performs other duties as assigned.

Education/Experience Required

• High School Diploma/G.E.D. 2 years’ experience, preferably in related area.
  
  
  
  Knowledge, Skills & Abilities Required:
• Good communication skills.
• Ability to work as a team member.
• Competent computer keyboard, laptop maneuvering, competent in Windows platform Basic computer skills and database entry.
• Good organizational skills. Ability to handle difficult calls and maintain professional conduct. Willingness to be flexible with job responsibilities
• Spanish-speaking a plus
  
  
  
  Physical Requirements and Working Conditions:
• Able to navigate city driving/find specific residences
• Hold valid/active driver’s license , own or have consistent/dependable access to vehicle that meets daily task requirements with proof of active and lawful car insurance.
• Familiarity with and experience working in designated
• Passion for and dedication to working with community members
• Excellent phone mannerisms Ability to effectively engage conversation, motivate and engage patients to participate in our program, and speak to all types of patients, particularly seniors.
• This position may include some home visitation with the care team. Less than 20%

The position will be located at Aurora Sinai in the Center for Senior Health and provide referral and resource navigation to patients and families participating in the program.

This job description indicates the general nature and level of work expected of the incumbent. It is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities required of the incumbent. Incumbent may be required to perform other related duties.

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