COMPASS - CARE NAVIGATOR at The Institute for Family Health

SUMMARY:

The COMPASS Care Navigator is responsible for managing a caseload of patients living with HIV that are enrolled in the Care Coordination Program. The Care Navigator works as a part of a diverse, multi-disciplinary team, playing a vital and active role supporting the HIV health of their patients. The position works with their patients to address barriers to HIV treatment, viral suppression, or engagement in care as well as supporting patients to become physically and mentally health while living with HIV. The role is a mix of field-based and in-clinic types work, as well as community outreach efforts to connect patients to healthcare.

The mission of the COMPASS Programs is to provide individualized, patient-centered, comprehensive services, rooted in harm reduction with an anti-stigma, anti-racism, social justice lens. The COMPASS Care Navigator is an active participant in reaching this mission, and moving COMPASS programs to embody this mission.

COMPASS Programs are committed to hiring candidates that are reflective of the many diverse identities of our patients. Candidates that are from diverse identities and communities are strongly encouraged to apply.

RESPONSIBILITIES:

• Assists with the screening of all patients receiving HIV primary care at Institute sites for eligibility in the Care Coordination Program
• Meets with enrolled and not-yet enrolled patients when they present for medical care or seen in the community, to engage in services and screen for needs
• Carry out field and clinic based outreach, to re-engage patients to care
• Sees, supports, and outreaches patients according to program guidelines, to ensure services are delivered with timeliness and quality
• Responsible for independently monitoring their caseload to: track upcoming appointments, make appointment reminder and missed appointment outreach calls, make collateral and referral follow-up calls, engage in health education, and address viral suppression
• Assists with the completing of program intakes, reassessments, care plans, and self-management assessments, when needed
• Engages patients in individual sessions of health education, adherence counseling, harm reduction, barriers to viral load suppression and care through home, field and clinic based visits
• Regularly assesses concrete needs, and supports patients via case management and care coordination efforts
• Provides accompaniments for patients to attend healthcare and social service appointments
• Regularly screens patients for mental health and substance use needs, assesses readiness for change and referrals, and refers for relevant resources
• Provides occasional crisis intervention with the help of managers, as needed
• Works closely with medical providers, nursing staff and others (internally and externally) to coordinate care for patients, through formal and informal case conferences, huddles, warm hand-offs, joint visits, referral/collateral contacts
• Conducts creative outreach, using various strategies, to re-engage patients previously out of care several months
• Completes timely and thorough documentation in Epic of all patient contacts.

• High School diploma or equivalent required
• Bachelor's degree in social work or in related field preferred
• Experience working with marginalized and underserved communities preferred
• Experience working in HIV care, medical or social service preferred
• General knowledge of HIV prevention and treatment
• General knowledge of the impact substance use, mental health, and stigma have on health outcomes and engagement in services
• Demonstrated organizational, interpersonal, oral and written communication skills and the ability to handle multiple assignments at any time
• Familiarity with concepts of the stages of change, principles of harm reduction, and elements of motivational interviewing
• Ability to engage with patients from many diverse communities, using an anti-racist, person-centered, and judgement free lens

As a member of the IFH community, we expect employees to: adhere to the organization’s policies regarding time, attendance, and dress code; demonstrate reliability and trustworthiness; manage time and resources to meet established goals/projects within the agreed upon time frames; demonstrate accountability; maintain patient/employee confidentiality; meet applicable regulatory and annual health assessment requirements; self- identify learning strengths and needs; demonstrate a professional, courteous, and respectful attitude in dealing with patients, families, significant others, members of the staff and extended community.

PHYSICAL DEMANDS

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is regularly required to stand; walk; sit; and use hands to finger, handle, or feel. The employee is frequently required to climb or balance and talk or hear. The employee is occasionally required to stoop, kneel, crouch, or crawl. The employee must occasionally lift and/or move up to 10 pounds. Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception, and ability to adjust focus.

WORK ENVIRONMENT

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Equal Employment Opportunity/Affirmative Action:

The Institute for Family Health is an Equal Employment Opportunity Employer. This job summary is intended to be brief and may not list all the duties and functions required, however, it does highlight the essential requirements. Nothing outlined in this job summary is to be construed as an express or implied contract of employment.

Please visit www.Institute.org for more information.