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The Health Homes Care Coordinator will work with patients enrolled in the Health Homes Program that require a high level of care. The Health Homes program works to create a Health Action Plan (HAP) for individual patients and then works with the patient's care team and support system to update and adjust the HAP based on the patient's progress.
1. Works with patient, their support system, and the healthcare team to create a Health Action Plan (HAP) for all Health Homes patients and other patients requiring care and ensures the goals of the individual patients HAP are being met.
2. Acts as a liaison between patient, healthcare team, and any outside resources to help the patient follow the HAP.
3. Provides Health Homes Project (HHP) services and implementation of the HAP.
4. Offers services where HHP members live, seek care, or find the most easily accessible setting within applicable guidelines and accompanies HHP members to office visits, as needed and according to applicable guidelines.
5. Connects HHP members to other social services and support the patient may need.
6. Advocates on behalf of members with health care professionals.
7. Uses motivational interviewing and trauma informed care practices to engage patients in care.
8. Works with hospital staff on discharge plans.
9. Monitors treatment adherence an informs teams of any changes or lack of adherence.
Education and Knowledge, Skills and Abilities
- Experience managing multi-disciplinary care teams.
- Understanding of high need patient population.
- Experience working with people experiencing homelessness, criminal justice, or other underserved populations.
- Experience with trauma informed care and harm reduction.
- Understanding of Social Determinants of Health and impact on patient well being.
- Ability to enter data into various electronic systems.
- Professional, punctual, flexibility and reliability imperative
- Excellent verbal, written, and interpersonal skills
- Integrity to handle sensitive information in a confidential manner
- Action oriented.
Minimum Education Required