Full-Time Health Navigator
The Summit Community Care Clinic (SCCC) Health Navigator will promote, maintain, and improve individual and community health by supporting patients in adopting healthy behaviors. The Health Navigator shall utilize clinic data to drive programmatic decision making. This person will be responsible for tracking quality assurance measures, reducing barriers to accessing care, and identifying needs of our patients and the clinic.
The Health Navigator may assist in development and implementation of health education programs. They may research and develop health education materials. They will facilitate related support groups, implement health education courses and conduct outreach programs. Health Navigators will coordinate publicity for programs, events, and related activities. They may facilitate projects or activities related to attaining or maintaining accreditation, conduct or participate in research projects related to health issues, and provide skill training related to health issues. Other tasks may be performed as required.
Health Navigators must demonstrate the clinical knowledge and judgment to assess, plan, implement, provide, and evaluate each patient’s educational care. They must demonstrate regard for the rights of all patients and provide respectful and considerate care focused on the patient’s individual health educational needs. Health Navigators will provide a safe and confidential environment for patients, families and personnel.
Health Navigators must demonstrate accountability and responsibility for duties and tasks associated with the position. They must acquire, maintain and demonstrate appropriate knowledge level and competencies for all tasks associated with the position. The schedule of the Health Navigator may vary, including some evening and weekend hours as needed.
Patient Overview, Assignments & Case Load: Health Navigators will meet with medical providers at the morning “huddle” to review the appointment schedule for the day and determine which patients will need Health Navigator visits. Providers will consult with the Health Navigators to decide which programs/resources will be offered by the Health Navigator for their daily case load. Areas of focus are diabetic patients, patients who need information regarding weight loss options, women’s health/reproductive health, behavioral health brief interventions or other health issues where an “Action Plan” and/or follow up is needed. Health Navigators may also see patients that are assigned or requested throughout the day by medical provider/dental provider/behavioral health provider/clinic assistant
Documentation: The Health Navigator is responsible for thoroughly and accurately documenting each patient visit in a “Health Navigator” note in the electronic health record, (Aprima). Documentation must contain quality information that accurately reflects patient encounters.
Hours: Ability to work Mon, Tues, Weds, and Thurs 10-7pm, and Fri 9-5. An hour lunch break provided daily.
Patient Navigation/Case Management Services: The Health Navigator uses resources to anticipate, address, and overcome barriers to care and to guide patients through the health care system. Health Navigators help improve the quality of care patients receive by coordination and navigation of services for patients. Health Navigators may assist with coaching or action planning, filling out paperwork, finding and arranging transportation to medical appointments, identifying local resources (including elder or child care), effective communication with health care professionals, encouragement and emotional support. Patient navigation is coordinated by a Health Navigator to guide patients through and around barriers in a complex system. Barriers to quality care may include financial and economic, linguistic and cultural, communication, complexity of the system, transportation, and bias based on culture/race/age, and fear. Additionally, Health Navigators may be responsible for maintain and managing patient registries such as prenatal, diabetes, controlled substances.
Referrals: It may be necessary for Health Navigators to use case management and patient navigation to ensure that the patient successfully attends their visits. Health Navigators may coordinate with the referral coordinator interpreter, or nursing to facilitate best care for patients. (Case management is used when necessary to coordinate patient care services to improve the quality of the total patient experience.)
Use of Educational Materials and Resources: The Health Navigator utilizes evidence based practices and materials when creating resources for patients. The Health Navigator shall control and maintain approved materials and resources in a predetermined location. (Evidence-based practice (EBP) “entails making decisions about how to promote health or provide care by integrating the best available evidence with practitioner expertise and other resources, and with the characteristics, state, needs, values and preferences of those who will be affected. Evidence is comprised of research findings derived from the systematic collection of data through observation and experiment and the formulation of questions and testing of hypotheses.)”
Support with Medication Compliance: Health Navigators shall:
• Educate and counsel patients, help determine answers to medication related questions through consultation with the prescribing provider;
• Inform patients and determine eligibility for state and federal programs that provide free, low cost or discounted medications, including the Medicare Drug Benefit, and patient assistance programs sponsored by pharmaceutical companies and private foundations;
• May assist patients with the enrollment process for prescription assistance programs and insurances;
Outreach: Organize, coordinate, facilitate and participate in county and statewide outreach events to increase awareness of our programs and services. Provide presentations on general health, disease-related topics and up-to-date information on health and prescription coverage, assistance programs and legislation. Update outreach calendar on a monthly basis.
Cultural Competence: Provide culturally competent health education strategies and techniques for patients by determining key components of cultural competence. Develop recommendations to implement culturally competent interventions to improve the quality of health care for patients when needed, which may include, but not limited to interpretation services, developing health information for patients that is written at the appropriate literacy level and is targeted to the language and cultural norms of specific populations. Collection of race/ethnicity and language preference data is also required.
Topic Specific Duties:
Diabetic Education: See every patient with diabetes at every diabetic follow up visit
• to discuss the “Defeating Diabetes Monthly Topic”;
• to discuss smoking cessation with appropriate patients;
• to determine and follow up on self-management goal;
• for patients just diagnosed, introduce “Basic Diabetes Information”.
Diabetic Groups: Health Navigators will assist in the coordination and implementation of the monthly and quarterly diabetic groups including making arrangements for guest speakers, assisting in determining topics, compiling educational materials, creating presentations and assisting in the facilitation of the group. Health Navigators will design sessions to benefit both type 1 and type 2 diabetics with the goal of keeping the group informed and motivated and to stay as healthy as possible. They will track and monitor attendance and follow up with individual patients as needed.
Women’s Health/Reproductive Health:
• Collaborate with medical providers to ensure that women are scheduled for screening and diagnostic mammograms within the guidelines of funding programs;
• Provide patient navigation for breast and cervical diagnostic and cancer treatment services;
• Follow up with referred patients to ensure they complete services and receive results;
• Assist with grant management and tracking of funding streams;
• Follow protocol for delivering comprehensive reproductive health information to patients;
Nutrition counseling/Weight Loss:
• Review basic principles of weight loss;
• Identify achievable and culturally relevant strategies for weight loss;
• Provide encouragement and tracking of self-management goals and action plans;
• Offer appropriate adjunctive services based on provider recommendations such as exercise classes and acupuncture.
Warm Referrals: Provide Behavioral Health Intervention to those patients with low acuity behavioral health issues:
• Respond to requests for BH interventions per the PHQ referral protocol.
• Assess patient’s level of readiness for change
• Offer appropriate evidence based behavioral intervention
• Refer to BH therapists as needed: at request of patient, or upon disclosure of more complex BH concerns up to and including suicidal ideation.
• Regular ongoing supervision and training with BH director
• Follow up and outreach to patients seen for a warm referral (by HE or BH)
Universal Drug and Alcohol Screening: The Health Navigator will provide Universal Drug and Alcohol Screening, Brief Intervention, and Referral to Treatment (SBIRT) to every qualified patient annually. Health Navigators will ensure the coordination of a universal prescreening for alcohol and other drug use and identify people with risky substance use. For those with a positive prescreen, further screening should be used to identify the appropriate level of intervention required. Screening can be through interview and self-report using validated screening tools such as the AUDIT and DAST for adults and CRAFFT for adolescents.
It is important to define clear boundaries and properly define the role and functions of a Health Navigator. Navigators who are not health care professional should NEVER:
• Provide physical assessments, diagnoses, or treatments;
• Order care, treatments, or medications;
• Attend to or become involved in activities that are out of the scope of the position (eg, changing dressings, providing direct financial assistance, picking up patients for appointments);
• Offer opinions about any aspect of health care delivered within or external to the organizations;
• Provide recommendations or opinions about physicians or health care organizations.
Tasks may change and/or additional duties may be assigned:
• Provides individualized health coaching to clients in obtaining their health objectives
• Supports patients in learning how to make good choices for themselves
• Teaches patients about managing their mental health.
• Co-facilitates groups/classes to support improved health outcomes.
• Self-directed and able to organize and manage multiple tasks/projects simultaneously
• Completes all tracking, notes and reporting requirements for outcomes and evaluation.
• Assists in the workflow of the Prescription Assistance Program.
Qualifications: To perform this job successfully, an individual must be able to engage in each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Education/Experience: At least one (1) year experience in a clinical setting or equivalent as a combination of education and experience. Previous non-profit and/or volunteer experience. (Bachelor’s Degree or equivalent). Certification in Motivational Interviewing. CPR certification.
Language Ability: Ability to read, write and clearly speak the English and at least intermediate Spanish language, ability to interpret a variety of instructions and deal with multiple variables.
Reasoning and Mental Ability: Ability to define problems, collect data, establish facts, and draw valid conclusions. Ability to exercise independent judgment. Self-directing and organized. Ability to reason objectively. Ability to assess, project and plan for patients needs. Ability to interpret state/ federal/agency regulations. Ability to document concisely, accurately and in a timely manner. Ability to handle a variety of duties which may be interrupted or changed by immediate circumstances.
Interpersonal Skills: Ability to relate cooperatively and constructively with patients, co-workers, administration, physicians and providers, community agencies, referral sources, regulators and other health team members. Ability to enlist the cooperation of others. High tolerance for stress.
Computer Skills: To perform this job successfully, an individual should have a solid knowledge of word processing software, spreadsheet software and database software.
Certificates and Licenses:
OSHA required courses for positions, BLS, or obtained within 30 days of hire.