Providence Community Health Centers
Full time 40 hours
MWF 8am-5pm; Tu & Thurs 11am-8pm
Associates Degree Minimum
Bilingual Spanish Preferred
Hiring for Multiple Openings!
Under the direct supervision of the Supervisor of the Community Outreach Advocates, the Community Outreach Advocate (COA) will work in collaboration with the primary care team to identify and remove barriers to close gaps and to facilitate patients in obtaining quality health care. This position supports all case management programs across all sites, as well as other Accountable Entity related initiatives.
Screens individuals seeking services and evaluates eligibility for programs offered. Identifies available community resources, providing information, and referral services. Maintains detailed records on outreach, enrollment, and case management. Participates in awareness-building activities such as training programs, forums, and panel discussions. The COA will provide outreach to the full age spectrum of patients and/or their caregivers of the Providence Community Health Centers. 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 (i.e. Blue Stream); this requires off site travel throughout RI. As a member of the local community, the COAs 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. 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
- Perform remote patient monitoring enrollment and follow up procedures within the scope of the COA
- Perform pre-visit planning for patients engaged in designated programs
- Perform closure of quality gaps per standing orders and procedures
- Provide home find and home tenancy interventions
- Assist, identify resources, and/or teach patients with complex barriers that are engaged in COA programs to schedule and track appointments
- Assist, identify resources, and/or teach patients with complex barriers that are engaged in COA programs to utilize transportation services
- Assist, identify resources, and/or teach patients with complex barriers that are engaged in COA programs to overcome language barriers
- Educate patients on the proper use of the health care system (i.e. PCP availability, express care, urgent care, ER, 24-hour on-call provider, same day access, BH Links, Kids Link, etc.)
- Support interpretation with patients for other care management staff that do not speak the patient’s language
- Support translation of care plans for patients
- Work independently with patients to help patient develop their self-management skills and successfully meet care plan goals
- Provide information to patients about community resources and help patients access resources
- Utilize motivational interviewing skills and other patient engagement techniques with patients and caregivers
- Act as an advocate for patients/caregivers to support the patient centered plan of care
- Participate in interdisciplinary care team meetings/case conferences
- Attend assigned site meetings as identified by the COA supervisor
- Take personal responsibility for professional development and maintenance of certifications, which can include specialty trainings offered by the RIDOH and CHWARI
- Attend community meetings as identified by the COA supervisor such as patient resources/supports and professional support; this may occur outside of normal work hours
- Track and document referrals made on the patient/caregiver’s behalf using PCHC approved technologies (such as use of Unite US platform and/or the EHR)
- Outreach and engage patients/caregivers into ad hoc programs such as, but not limited to, the prescription produce/food as medicine program initiatives, legal resource classes, health eating habits classes
- Help patients with literacy barriers, this may include, but not limited to helping with navigation to complete applications if other community resources to do so are not available
- Represent the organization with a positive, professional attitude when communicating with patients and visitors of the health center
- Work well with others and can discuss in a professional manner any issues that come up with other staff
- Attend team meetings and read meeting minutes to establish an understanding for the content; it is the COAs responsibility to establish understanding of what occurred in the meeting if they are unable to attend
- Adhere to a predictable schedule as outlined in the offer letter
- Support community awareness around public health crisis, resources, and access to (i.e. COVID or Flu testing & vaccines)
- Support tracking and reporting of success stories
- Support tracking and reporting of qualitative data related to patient barriers, care, and services provided
- Adhere to HIPAA regulations
- Support precepting new staff
- Participate in departmental team building activities
- Home and community visits required per program procedures
- Accompanying patients to appointments after review and evaluation with supervisor or director for select high risk cases when patient is engaged with and/or known to a case management team member
- Unannounced home/community visits after review and evaluation with supervisor or director for select high risk cases when patient is engaged with and/or known to a case management team member; must be accompanied by a peer or supervisor
- Bill appropriately for services provided while assuring documentation to support billed services
- In addition to the organizational EHR, required to document in other PCHC approved systems such as, not limited to, UniteUs, HMIS, etc.
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.
Essential Education, Experience, Skills:
- 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.
- 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
- 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
Essential Working Conditions and Environment:
Ability to read, analyze, and interpret, professional journals and technical procedures. Ability to research and write detailed reports, business correspondence, and procedure manuals. Ability to effectively present information and respond to questions. Ability to read and interpret documents, regulations and procedure manuals. Ability to effectively present information by telephone and in one-on-one encounters.
Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals. Ability to compute rate, ratio, and percent and to draw and interpret bar graphs. Knowledge and ability to research capture data, prepare detailed and complicated reports in and electronic fashion.