Program Description and General Responsibilities:
Health Homes is an outreach program which engages with clients (including pediatrics) in the community into health and social related services to best meet their needs. Care Coordinators must take mandatory training and become certified as Care Coordinators through a WHA approved program. Once certified Care Coordinators will provide the six pre-defined Health Home care coordination benefits. Benefits must be provided through high touch, in-person utilizing Care Coordinators from the following disciplines: Registered nurses, licensed practical nurses, Physician’s Assistants, BSW or MSW prepared social workers, and Chemical Dependency Professionals. Health Home (HH) Services are intensive services that coordinate care across several domains, as defined under Section 2703 of the Affordable Care Act of 2010. The purpose is to coordinate the full breadth of clinical and social service expertise for high cost/high risk beneficiaries with complex chronic conditions, mental health and substance use disorder issues and/or long term service needs and supports. The services provided by Health Homes Care Coordinators are 1) Comprehensive care management; 2) Care coordination and health promotion; 3) Comprehensive transitional care from inpatient to other settings, including appropriate follow-up; 4) Individual and family support, which includes authorized representatives; 5) Referral to community and social support services, if relevant; and 6) The use of HIT to link services, as feasible and appropriate.
Essential Functions: (Tasks, Responsibilities, and Competencies. May not include all duties of this job)
Accept, respond to and process referrals received from Lead Entities including; North West Regional Council, Molina, CHPW, Amerigroup etc.
Engage in outreach activities to contact clients including mail and phone, and participate in face to face visits with clients in a location of the clients choosing such as their own home if needed
Obtain necessary consents and complete a Health Action Plan on all new enrollees.
Conduct all required screening as defined by WHA on all new enrollees Utilizing required instruments which includes the following: Katz (ADL) , Patient Activation Measure (PAM) or Caregiver Activation Measure (CAM), PHQ9 (depression screening)
Carry out assessments to determine readiness for self-management and promote self-management skills to support the client in engaging with health and service providers
Support the achievement of individualized health goals designed to attain recovery, improve functional or health status or prevent slow declines in functioning
Work with client to identify short-term and long term goals, prioritize concerns and establish immediate action steps
Identify client health care problems through the combined review of medical records, PRISM and face to face visit with client
Foster communication between providers of care including PCP, medical specialists, personal care providers and others
Promote optimal clinical outcomes including describing how progress toward outcomes will be measured through health action plan
Provide health education and coaching to assist clients to increase self-management skills, improve health outcomes and which promotes continuity of care
Refer to and utilize peer supports, support groups and self-care programs to increase clients knowledge about their health care conditions and work to improve adherence to prescribed treatment
Make arrangements for transitional care from inpatient to other settings if needed
Ensure appropriate language and translation services are available to clients if needed
Maintain a contact log for each client including the purpose of each contact, identifying who interacted with the client
Ensure clients consent to participate in Health Homes
In preparation for in person visits with clients ensure clients PRISM information has been reviewed including 15 month history.
Build client specific Health Action Plans with relevant PRISM information and other information such as treatment plans, CARE assessments, previous screens and assessments.
Ensure clients HAP provides evidence of; chronic conditions, severity factors and gaps in care, activation level, opportunities for potentially avoidable emergency room, inpatient hospital and institutional use, self-identified goals, needed interventions and outcomes, transitional care planning, supports and interventions, using self-management, recovery and resiliency principles using person identified supports including family members and paid and non-paid caregivers
Provide mentoring and model communication with health care providers as needed through joint office visits and communications
Provide wellness and prevention education specific to the clients chronic conditions, including assessment of need and facilitation of routine preventative care, support for improving social connections and community networks and linking clients to resources that support a health promoting lifestyle
Link clients to resources for, but not limited to, smoking prevention and cessation, substance use disorder prevention, nutritional counseling, obesity reduction and prevention, increasing physical activity, disease specific or chronic care management self-help resources, and other services such as housing based on individual need and preferences
Ensure HAP is updated noting changes in needs/preferences/progress every 4 months
Report all suspected incidents of abuse or neglect of vulnerable adults and children as required as a mandated reporter
Travel to visit clients in their own homes or a mutually agreed upon location who are referred to the Program.
Provide comprehensive cross system case management services through the provision of in person visits, follow up by phone and in person and communication with other providers/professionals
Ensure that communication, coordination and care management functions are not duplicated by other case managers
Provide interventions that recognize and are tailored for the medical, social, economic, behavioral health, functional impairment, cultural and environmental factors impacting a client’s health and health care choices
Work with a range of agencies and providers to co-ordinate community care and services as needed for individuals including: Primary Care Physicians, Pharmacies, Home Care Agencies, Assisted Living Agencies, Adult Family Homes, legal representatives, other housing providers, private landlords, etc.
Arrange for services necessary for the client’s health and safety,
such as home accessibility adaptations, one-time cleaning services, and pest and allergen control as needed
Assist with locating and arranging transportation and other resources to effectively connect the individual with community resources.
Engage in creative outreach activities to best engage with ‘hard to reach’ adults
Assess clients’ presenting problems, formulate individualized health action plans, assess, monitor and document clients’ response to interventions. Evaluate effectiveness and revise plans regularly. Create individualized health action plan goals with clients.
Transport individuals in company or personal vehicle, as needed.
Respond promptly and appropriately to challenging situations and incidents as they arise, using sound problem-solving methods to meet client needs and reporting requirements.
Maintain accurate and timely records. Track, monitor and document items in accordance with policies, procedures and regulations.
Submit timesheets and case notes weekly and monthly as required.
Maintain knowledge of regulatory and policy requirements of the Health Homes Program, as well as the directives, standards, and strategies of the Community Placement Division Director.
Ensure that all activities are within the scope of Sunrise’s license and are in compliance with professional, legal, and regulatory standards.
Adhere to requirements of Sunrise Policy and those of Lead Entities / contractors
Analyze processes for effectiveness and compliance, and provide analyses and recommendations to the Program Coordinator.
Participate in assigned quality assurance, training, orienting, monitoring, and other functions.
Perform other duties as assigned.
Essential Requirements: (Any Equivalent Combination of Knowledge, Skills, Abilities, Education, and Experience)
Education and experience : Must meet one of the following criteria:
Behavioral Health Professional or Specialist – Mental Health Counsellor with Masters level degree in related field / Certified MH Counselor with Bachelors level degree in related field / Agency Affiliated Counsellor with Bachelors level degree in psychology / Bachelors level degree in related mental health field with 2-years’ experience
Registered Nurse, Nurse Practitioner, Licensed Practical Nurse
Social Worker – Masters or Bachelors in social work, human services or related field
Chemical Dependency Professional
Licensure/Certification :
Washington driver’s license
Current First Aid and CPR certifications
License related to qualifications listed above
Other Considerations :
Background clearance required including fingerprint.
Current valid Washington driver’s license with acceptable driving record.
$50,000 automobile liability insurance required.
Strong verbal and written communications skills.
Intermediate skill with Microsoft Office products including Word, Excel, Access and Outlook. Ability to learn additional software as assigned.
Lift approximately 20-30 pounds and physically assist unsteady clients.
Source: Indeed.com
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