Health Care Navigator - SSVF

Job Description

Job
Objective:

P
rovide services
connecting
SSVF eligible Veterans who are homeless or at risk of homelessness
to VA health care benefits
,
or community health care whe
n
Veterans are
ineligible
for VA care
.
P
rovide case management
,
care coordination, health education, interdisciplinary collaboration, consultation,
quality improvement, and risk management
working
with the Veteran's primary care provider and
the ass
igned interdisciplinary treatment team.

Essential Functions:

This job description should not be interpreted as all inclusive. It is
intended
to
identify
the essential
functions and
requirements of the position. Other
job related
responsibilities and tasks may be assigned
.
Reasonable accommodation may be made to enable individuals with disabilities to perform the essential job functions.

Non-Clinical Assessment:

Following intake, engage Veterans in a non-clinical assessment of the Veteran's health/mental health situation, potential barriers to care, causes, and the impact of barriers on the Veteran's ability to access and
maintain
health care services. Obtain secondary and tertiary information in collaboration with the i
nterdisciplinary team, family members,
health care providers,
and significant others

to develop a comprehensive understanding of the Veteran's health care needs.
Ensure that
appropriate releases
of information are
obtained,
and that confidentiality requirements are
observed
.

Health Care Team and Veteran Communication
:

Work
closely with Veterans
and
assist

in communicating
Veteran care
preferences
and
personal
health
goals
to health care providers and
to
facilitate
shared decision making of the Veteran's care.
Serve
as a resource for education and support for Veterans and
families
and
identify
appropriate
Veteran-centered
supports.

Community Services, Outreach, and Referrals to Support Veteran's Care Plan:

Develop the
Veteran's
SSVF health
care plan
with an
emphasis on community services, outreach, and referrals needed for the Veteran.
Develop the plan
in collaboration with the interd
isciplinary treatment team,
Veteran, family members, and significant others
; incorporating
measurable goals.
Regularly review care plan goals with the Veteran, conduct ongoing non-clinical barrier assessments, and provide
resources and referrals needed to support adherence.
Evaluate
effectiveness of
r
esources and referrals provided and make

modifications to ensure provision of high-quality care and interventions.

Monitor and document progress and provide updates to the team as appropriate
.

Specialized Case Management and Care Coordination
:
Provide
comprehensive case management and care coordination
across episodes of care acting as a
health coach by proactively supporting the Veteran to
optimize
treatment interventions and outcomes.
Mo
dif
y
services to meet the
Veteran's
needs and coordinate services with other organizations
/
programs to
assure

provision of complementary and comprehensive
services
.

Represent the
program in
contacts
with other agencies and the public.
C
oordinate
additional

supportive services
to
ensure
Veteran
and caregivers are linked to
supportive services,
including
but not limited to, housing, financial benefits,
and
transportation.

Coordinate
referrals to VA, community health clinics, and other programs needed to ensure access to health care.
Follow the
care plan to facilitate
adherence, and
collaborate with community providers to maximize
use
of VA and community resources.
Act as
an advocate for the client, integrating the Veteran's cultural values into the care plan.
Assist Veteran to
identify methods to monitor progress toward meeting health goals
.
Provide ongoing

follow-up
.

Health Education:

E
ducate Veterans and
caregiver
s
on available services and
assist
with referrals based on Veterans preference
s
.
Assist
in
identifying
the Veteran and family's health education needs and
provide
education services and materials that match the health literacy level of the Veteran.
Provide
ongoing education support as needed
based on
identified
needs.

Interdisciplinary Collaboration, Coordination and Consultation
:

To
promote the highest level of
quality car
, collaborate with the health care provider, interdisciplinary care team, and the SSVF team, regularly consulting on ongoing assessment of Veteran needs. Act within professional boundaries and roles appropriately, respecting the roles of others involved in care and services
.

Risk Management & Infection Control:
Complete required training
including:
Safe from Harm, Blood Borne Pathoge
n
s, The Salvation Army
's
Case Work Certification
Program
,
Confidentiality, Ethics
, Suicide Prevention
, and all SSVF
Health Care Navigator training.
Report any accidents or injuries to self or clients and complete
appropriate documentation
.
Follow risk management plan
,
infection control practices
(i.e., hand washing, universal precautions/isolation procedures, and precautions), follow protocols
specific to COVID-19 prevention
, and all safety
protocols vital to staff and Veteran safety
.

Confidentiality
, Computer Security,
and Ethical Practice
:

Adhere to ethical standards of practice and principles
of
confidentiality, informed consent, compliance with relevant laws, and agency policies (e.g., critical incident reporting, HIPPA, Duty to Warn).
Ensure client confidentiality is
maintained

in accordance with
established procedures and regulations.

Contin
uous Quality Improvement (CQI)
and Systems Improvement
:
Part
icipate
in expanding knowledge related to health care navigat
ion with
the Veteran population.
Collaborate with supervisors
to review research-based best
practice
and make suggestions on improvements to HCN service delivery.
Participate in case reviews and progress updates in team meetings. Submit monthly reports
as
required
on activities and
unmet needs
.
Attend in-service and outside
trainings
as requested
.
Assure
service delivery in compliance with VA-SSVF program regulations, SSVF Program Guide, SSVF policies/procedures, The Salvation Army's policies/procedures, 38 CFR Part 62, and policies/procedures/waivers specific to COVID-19

as instructed by the VA-SSVF Program Office
.

Customer Service:

Participate

effectively in team meetings
, case
conf
erences, and related activities.
Collaborate with multidisciplinary team members
to enhance c
oordination of comprehensive Veteran care. Effectively communicate
and
utilize
community agencies to

facilitate
continuity of care.

Age, Development, and Cultural Needs of Veteran Clients:
Consistent sensitivity to all Veteran's needs concerning age, developmental requirements and culturally related factors and consideration of age
-
related differences in the provision of care.

Minimum Qualifications:

The requirements listed below are representative of the minimal education, experience
, certifications
,
skills, and/or abilities
required
for this position.

Education
:

Bachelor's degree

required
but years of experience noted below may substitute
.

Experience
:

Pr
ior experience performing m
edically based
case
managemen
t

preferred
, e
xperience
serving homeless population and Veterans preferred
, and prefer
experience with crisis intervention
and community resources
.

Certifications
/Licenses
:

None
.

Skills/Abilities
:
Ad
vanced
case management
skills

in a medical or medical case management environment and an
ability to function independently while seeking
supervisory
consultation
.

E
xercise
sound judgment
and initiative in
day to day
activities based on
expertise
accumulated through education, training, experience, and staying abreast of best practice literature.
C
ompetent in use of
computer technology for documentation
,
date
entry,
and
virtual technologies.
Must concentrate mental and visual attention closely on work for sustained periods, employ critical thinking, and creative problem solving.

Skills/Abilities/Competencies & Key Performance Indicators:
These are the skills, abilities, competencies, and key performance indicators that the employee is expected to
demonstrate
in the performance of their
position
and which is evaluated annually:

Collaboration &
Team Work
:
Builds good working relationships, collaborates, and cooperates with staff, supervisors, managers, and other organizational departments, outside agencies, and other community partners. Works effectively as a part of a team to achieve organizational and program goals.
Shows
respect for others and values their contributions. Shares ideas and contributes to greater productivity in meeting shared goals
.

Attendance & Timeliness:
Consistent, good attendance, and punctuality are essential to satisfactory performance of job duties. Demonstrates the ability to prioritize tasks and manage work effectively. Completes work on time and
meets
deadlines. Responds promptly to supervisory and management requests.

Communication:
Communicates with co-workers, supervisors, managers, clients, vendors, and community partners in a cooperatively respectful professional manner. Listens effectively to the ideas and perspectives of others to seek understanding. Expresses thoughts and ideas easily in groups, teams, and one on one conversations. Written and verbal communications are professional, clear, concise, and articulate relevant information using Standard English. Ability to communicate using terminology and language unique to The Salvation Army and SSVF program. Demonstrates effective presentation and public speaking skills
.

Financial Impact:
Values, guards, and uses efficiently, the assets and resources of The Salvation Army and the SSVF program, including grant funds. Completes annual fraud prevention training and follows fraud prevention and risk management protocols. Initiated an idea that could be implemented to reduce operational costs/expenses or that could potentially increase revenue for the program or The Salvation Army.

F