Purpose: To empower eligible clients to improve their quality of life based on priorities and goals set by the individual. Coordinate services with clients by providing support and assistance with navigating systems through collaboration with our multidisciplinary team and community professionals. Work in a proactive manner to limit the need for crisis intervention and to promote independence. To provide the timely, high quality services that will assist in reducing avoidable health care costs and improved client outcomes by providing support, education, outreach and engagement activities.

Key Job Responsibility Areas

• Care Management

• Linkage, Engagement & Retention

• Advocacy & Direct Client Services

• Staff & Intern Orientation & Development

• Miscellaneous

  Detail of Key Job Responsibility Areas

  1. Care Management

• Provide care management services to LGBTQ+ individuals that are person-centered, quality-driven and culturally appropriate in compliance with agency policies and/or funder requirements.

• Assist assigned clients in the reduction of negative health outcomes and avoidable health care cost; specifically focusing on one or more of the following:

• reducing preventable hospital admissions/readmissions

• decreasing avoidable emergency room visits

• improving access to care & continuity of care (ex. follow-up of tests and referrals)

• Improve patterns of care utilization, including promoting adherence/compliance with medical recommendations

• enacting behavioral change(s) to improve overall health

• Assist clients in the successful management of all aspects of their care. To do this, the following steps will be taken:

• Complete initial and ongoing assessment of the individualized needs of assigned clients

• Determine level of care/support best suited to supporting client success.

• Create, document, execute, monitor and update an individualized plan of care for each client that incorporates a holistic array of health goals/needs that are clearly identified, with timelines, and includes interventions that will produce positive outcomes

• This plan must be client-centered and created in partnership with the client; and should be informed by the input of all relevant members of care team including the client, care provider, care manager and other connected social &/or support services

• At periodic re-assessments, make indicated adjustments to plan based on client’s identified needs/desires.

• Provide on-call support when assigned.

• Coordinate and provide access to preventive and health promotion and/or other ancillary services and community resources as needed; including mental health and substance use services.

• Promote client health outcomes through coordination of each client’s care team by

• Building relationships with client and with all involved service providers.

• Coordinating and participating in regular case review meetings that include all members of the interdisciplinary care team

• Demonstrate the ability to use the health information technology system to coordinate and link services

• Identify available community-based resources and actively manage appropriate referrals, access, engagement, follow-up and coordination of services

• Maintain comprehensive and accurate written documentation of all client interactions.

• Demonstrate developing knowledge of community resources.

• Adhere to all government, funder, agency and department regulations.

  2. Linkage, Engagement & Retention

• Link hard-to-reach and/or lost-to-care clients to needed services by providing specific outreach services to them.

• Outreach services may include telephone and/or in-person contact in community settings; and home visits and hospital visits to meet with clients & approved collaterals when appropriate.

• When outreach services identify barriers/needs, oversee the engagement of steps to address them including: coordinating transportation for clients, escorting them to and from appointments, and identifying other community resources to reduce barriers.

• Demonstrate developing knowledge of community resources.

• Participate, as directed, in ongoing outreach services, both in-person and online/social media, conducted through the Community Health Initiatives team; specifically focusing on outreach activities that target LGBTQ+ community members and venues with the goal of recruiting and retaining them in high quality ongoing medical care.

• As part of the LGBTQ+ Health team, participate in the creation of health messaging targeting LGBTQ+ individuals; the dissemination of such materials through the use of social marketing technologies, print & electronic materials to be distributed in community venues and in both LGBTQ+ and mainstream press.

• Participate in the ongoing use and maintenance of program-specific social media including agency/program website and social media platforms.

  3. Advocacy & Direct Client Services

• Act as an advocate for both individual clients and for the LGBTQ+ community around issues of access and cultural appropriateness of the care they receive.

• Promote client access to appropriate internal agency services including, but not limited to: support groups, housing services, daily bread, behavioral wellness, substance use treatment, and medical care.

• Orient clients to services available within the agency and to the mission at Trillium Health.

• Advocate for client access to entitlement programs, treatment facilities, and other needed community services.

• Demonstrate developing knowledge of HIV/AIDS, STD and LGBTQ+-related issues.

• Participate with the DEB team in the development and delivery of LGBTQ+ health and cultural competency training(s) directed at the general community and present /future healthcare & human service providers in order to expand the array of culturally appropriate services available to LGBTQ+ communities.

• As needed, participate in the delivery of structured interventions including DEBIs specifically aimed at decreasing risk and/or improving health outcomes for LGBTQ+ populations.

  4. Staff & Intern Orientation & Development

• Responsible for orienting new staff and interns (BSW and MSW) to the team to include:

• Completion of department orientation and onboarding processes

• Training of grant guidelines, procedures and documentation requirements;

• Facilitating introductions to other departments/teams that are integral in the performance of job responsibilities/internship competencies (clinic team members, testing team members, etc.);

• Training of MEDENT forms and processes specific to job role and responsibilities/internship competencies;

• Mentorship through observation and feedback re: patient meetings, document completion (notes, assessments, service plans, crisis plans, etc.)

• Development of internship opportunities that align with core competencies expected of BSW/MSW internship curriculum

• Evaluation of performance for BSW/MSW interns utilizing evaluation tools provided by educational institution

  5. Miscellaneous

• Requires the ability and commitment to respect and support inclusiveness and diversity including but not limited to individuals of different backgrounds, cultures, races, ages, sexual orientations, gender identities or expressions, experiences, opinions, etc.

• Requires individual demonstration of commitment to the One Trillium behaviors and business impacts and modeling them in the organization.

• Responsible for maintaining confidentiality of all client & employee protected and proprietary information.

• Employees are accountable for meeting the performance standards of their departments and must participate as requested in compliance audits, process improvement and quality improvement plans.

• Other duties as assigned.

  Qualifications

  Bachelor’s degree in health, human or education services and/or a minimum of one year of qualifying experience including care management or casework with persons who have HIV infection, a history of mental illness, homelessness or chemical dependence; OR an Associate degree in health or human services and two years of qualifying experience Computer proficiency is required. Fluency in Spanish and/or ASL preferred. Must be affirming of diverse populations.

  Physical Requirements

  While performing the duties of this job the employee is required to stand, sit, walk. Occasionally the employee must stoop or bend.

  In support of the Americans with Disabilities Act, this job description lists only those responsibilities and qualifications deemed essential to the position.