CARE NAVIGATOR MOBILE RETENTION

About Whitman-Walker Health

Whitman-Walker envisions a society where all persons are seen for who they are, treated with dignity and respect, and afforded equal health and well-being opportunities. Through care, advocacy, research, and education, we empower all persons to live healthy, love openly, and achieve equality and inclusion. For over 40 years, we have been meeting the needs of our communities with the endless dedication of our diverse teams.

Job Summary

The Care Navigator-Mobile Retention provides specialized support to HIV-positive adults who present with adherence-related issues that create barriers to returning to the Health Center for care through the Mobile Outreach Retention and Engagement (MORE) program. The Care Navigator-Mobile Retention provides a supportive and empathic relationship to the patient that is harm-reduction focused and serves to facilitate easier access to WWH services and those in the community by meeting patients outside the walls of the health center and providing education, counseling, support, and referrals in the community, in a patient’s home, or at one of WWH’s health centers.

This position partners with other community organizations to ensure collaborative service provision without disruption to care. The position requires outreach to the highest risk groups, and partnerships with key community and government partners to provide counseling, care, and risk management to these hard-to-engage adults. The position accompanies patients through Whitman-Walker’s services and assists in obtaining external referrals, while also helping the patient to establish a healthy support system and support ongoing retention in care.

The Care Navigator-Mobile Retention coordinates activities with the MORE team to ensure long-term retention in high-quality care and work with additional team members supporting the patient’s care plan- Nurse Care Managers, Medical Providers, Community Health workers, and other connections to community resources. The Care Navigator will participate in quality improvement (QI) activities to improve health outcomes and is responsible for accurately recording information about the services provided to mobile-medical patients. The Care Navigator’s activities will be conducted in healthcare settings, patients’ homes, and other community settings.

Core WWH Primary Essential Duties

• Perform and behave in accordance with Whitman-Walker’s mission, cultural norms, and core values of dignity, respect, affirmation, and humility.

• Maintain a respectful, non-judgmental, and compassionate manner with patients/clients/staff.

• Demonstrate excellent customer service by identifying and exceeding customer requirements.

• Adhere to Whitman-Walker policies and procedures, with special attention given to HIPAA

requirements. • Maintain data integrity through conscientious use of relevant tools and employing a system of checks and balances.

• Demonstrate organizational skills necessary to multi-task, meet deadlines, and re-prioritize as needed.

• Participate in organizational quality and performance improvement activities.

Role Specific Primary Essential Duties

• Works as part of a multidisciplinary team to provide specialty care to patients with adherence issues and/or unstable disease management status at patients’ homes, other community settings, and within the health center.

• Identifies patients in need of specialty adherence care, collaborating with medical and behavioral health providers and support staff to encourage referrals to the adherence team as appropriate.

• Provides outreach to these pre-identified patients and community agencies to promote collaboration and engagement with WWH’s mobile medical services

• Assists and guides patients through services at Whitman-Walker and outside agencies, serving as a representative and advocate of the patient and providing referrals when necessary.

• Makes regular contact with patients and develops individualized care plans to promote adherence to treatment plans and assists the patient in establishing a healthy support system that promotes long-term retention and addresses barriers to care

• Identifies barriers to retention and works with patients to overcome obstacles and gaps in care

• Prepares narrative and statistical reports as requested.

• Maintains up-to-date and accurate records in the electronic medical record (EMR) system or other data systems.

• Ensures patients receive necessary services from community organizations

• Follows-up with patients that are identified as being at risk of falling out of care or who have not been recently seen by the practice

• Maintains a current resource list of community service organizations

• Skill and/or comfort with the use of HIV/STD home testing kits to self-test and submit the specimens to the appropriate testing laboratory.

• Follow-up in person or through telephone contacts with patients who are hospitalized, have emergency room (ER) visits, miss clinic visits, miss medication refills, or have laboratory results that indicate that patients may not be fully adherent to HIV treatment regimens.

• Conduct outreach and home visits to patients who are lost to care, identify barriers to retention, and facilitate re-engagement in medical care.

• Coordinate with mobile-medical patients’ clinicians, medical case managers, behavioral health providers, or other healthcare providers to ensure that high-quality and culturally competent services are received.

• Participate in adherence training and ongoing in-service education arranged by Whitman-Walker Health to maintain professional knowledge.

• Document all work activities according to established standards, collecting data for production in weekly, monthly, and annual reports and assisting with the creation of those reports as necessary.

• Responsibilities include other duties as assigned, including special tasks involved in responding to an emergency event.

Budget Responsibilities

None

Management Responsibilities

None

Core Whitman-Walker Health Knowledge, Skills, and Talents Required:

• Ability to work independently with minimal supervision.

• Ability to manage time and effort in order to meet strategic objectives.

• Knowledge of principles and processes for providing excellent customer service, both internal and external.

• Knowledge of all applicable WWH policies and procedures.

• Excellent oral and written communication skills.

• Knowledge of healthcare information systems with the ability to adapt to new electronic medical records and population health platforms.

• Analytical skills necessary for the preparation of accurate, concise, and comprehensive reports.

• Ability to maintain records and information in an accurate, timely, and confidential manner.

• Ability to adapt to changes in the service delivery model, re-prioritizing as necessary.

• Flexibility to work various shifts, including afternoon, evening, and weekend shifts.

• Commitment to health equity.

Role-Specific Knowledge, Skills, and Talents Required

• Flexibility of schedule – shifts include regular evening and occasional late night and weekend hours.

• Knowledge of HIV/AIDS-related illnesses and substance abuse, including current treatment and adherence strategies and knowledge of risk reduction intervention strategies.

• Knowledge of chronic health conditions, such as diabetes, hypertension, heart disease, etc., with an understanding of the needs of individuals and families across the primary care continuum.

• Knowledge of techniques for assessing patients’ needs, developing risk-reduction and referral plans, identifying resources, making referrals, following up to ensure completed referrals, documenting patient interactions, and proactively supporting patients’ pursuit of goals.

• Ability to maintain appropriate judgment in interactions with patients and staff, including assuring Care Partner safety in conducting home visits.

• Knowledge of community resources and benefits that impact and/or benefit the targeted patients’ needs, including the Ryan White HIV/AIDS Program and Medicaid.

• Ability to travel with patients in and around the assigned geographic areas using public transportation.

• Understanding of and sensitivity to the needs of individuals with chronic medical conditions, including HIV, mental health and substance use issues, and other conditions.

• Strong interpersonal skills as demonstrated by compassionate, courteous, cordial, cooperative, and professional interactions with diverse groups of co-workers, external business partners, and the community.

• Ability to work in a multidisciplinary team structure by demonstrating the ability to collaborate and contribute to the team’s work.

• Adherence to all Whitman-Walker Health policies and procedures.

• Company-sponsored travel required, personal driver’s license and vehicle preferred

Education and Experience Required

• Minimum Experience: Two or more years of paid work experience providing direct assistance to a diverse population in public health, healthcare, human services, or other community settings. Experience with providing HIV and/or STI CTS and HIV outreach, linkage, and retention services preferred.

• Minimum Education: Bachelor's Degree in social work, human services, or related field or at least four years of direct experience required.

• Experience working with an ethnically, culturally, and racially diverse work staff preferred; ability to work harmoniously with diverse groups of individuals required.

Working Conditions:

Working conditions for this position are normal for an office environment. Individual may be required to work evenings and/or weekends and organization events.

Physical Demands:

• Lifting: No more than 20 lbs. and infrequently.

• Movement: Standing and sitting for long periods.

• Visual: Long periods on a computer.

• Concentration: Extended periods of engagement with computer systems where concentration is key to accuracy in data entry. Intermittent periods of engagement with a telephone system to respond to inquiries where concentration is key to task performance.

• Communication: Direct and indirect communication. Written and verbal competency.

Whitman-Walker is an equal employment opportunity employer and does not discriminate against applicants, its employees, or former employees on the basis of race, color, religion, gender, marital status, sexual orientation, national origin, age, disability, veteran status, and gender identity. For accommodation in the application process, please contact Human Resources.