WPIC Palliative Care Patient Navigator
Position Status
Site
NHC Position Type
Position Summary
About the Position:
People experiencing homelessness (PEH) often present in end stages of disease process and die at earlier ages than the general population. PEH have unique palliative care needs, including family configurations, shelter at end of life, complex pain, comorbid mental illness and/or trauma, mistrust of medical systems, and managing active substance use.
Whole Person Integrated Care has created a WPIC Palliative Care team to meet the needs of this special population. The Palliative Health Patient Navigator NHC Member will join the Primary Care team in weekly outreach to the Palliative Care cohort to develop skills and education about Palliative Care with People Experiencing Homelessness in SF and to discuss complex cases. The NHC Member will also support management of the referrals and outreach data to keep up to date records on the needs and gaps in the care of this populations, participate in weekly huddles to connect during the week and make collective decisions on who needs outreach and follow up, document patient care activities in EPIC, and respond to referrals for palliative care and general patient navigation.
About the Host Site:
SFDPH Whole-Person Integrated Care serves to provide care to people experiencing homeless by 1) connecting to transitional primary care 2) re-/connecting to social services 3) supporting client’s towards becoming “housing ready” for their transition from shelter health to their next destination, ideally their own permanent, supportive housing with established primary medical care.
The WPIC Palliative Care is a smaller team within the larger WPIC team that focuses their work on end-of life care and support and linkages. WPIC is a part of the San Francisco Department of Public Health.
Major Duties and Responsibilities
- Tracking patients to confirm program enrollment and engagement
- Providing follow-up and case management to deliver assistance and information
- Implementing patient engagement strategies to improve outcomes
- Educating patients on medical interventions and prevention
- Providing social service navigation
- Tracking, enrolling, and surveying patients for improvement
- Attending meetings and patient huddles.
- Assisting in care coordination and resource referrals
- Tracking referrals and closing the referral loop
- Linking patients to care by scheduling appointments
- Updating and maintaining client databases (EPIC, Excel) for program evaluation
- Support with data visualization of client-served in WPIC programs (ex. Palliative Care)
- Attending and participating in relevant meetings
- In-person outreach with multidisciplinary team
- Opportunities to present with team at conferences, trainings, and talks
Characteristics of an Ideal Candidate
- Able to review and synthesize information
- Able to build strong relationships
- Able to communicate effectively with all individuals.
- Comfort speaking with others, individually or in groups
- Community engagement/outreach skills
- Compassionate
- Creative problem solving skills
- Detail-oriented
- Flexible
Knowledge Required for the Position
- Knowledge of AmeriCorps/Health Corps member requirements
- Skill with Microsoft Office or other software for a variety of data processing operations involving a range of problem solving, record keeping, correspondence, and service tracking options.
Supervision
- The supervisor assigns service activities, advises on changes in procedures, and is available for assistance when required.
Review
- Completed projects are reviewed very generally to determine that objectives have been met and are in compliance with policies and regulations.
- Supervisors will perform supervision on a regular basis to check in around projects and activities, offering support if needed for completion and assigning new tasks as needed.
Guidelines
- Detailed guidelines exist, including regulations and directives, handbooks, precedents, industry standards, and files of previous projects
- There are guidelines for most situations but sometimes creative thinking is needed for problem solving in special situations, with the support from supervisor or staff member.
Complexity
- The facts or conditions of the service position are clear cut, predictable, and apply directly to the assignment.
Special Considerations
- Personal vehicles are not required for this position. The clinics are accessible via public transportation.
- The member will:
- Serve approximately 40 hours per week.
- Serve Monday-Friday from 8:00AM - 5:00PM.
- Significant travel (more than 25%) between clinics and service sites
- Outreach into the community and hospitals is a big part of the position.
Language Proficiency Requirements
- No language other than English is required.
- Proficiency and skill with Spanish, Cantonese, and/or Mandarin would be useful to the member to communicate with a wider range of people (administrators, teachers, parents, dentists, and children).
Criminal History Check Requirements Beyond NHC Standard Checks
- Upon Conditional Acceptance of an NHC AmeriCorps Position, all AmeriCorps members must complete TrueScreen Background Checks to be formally placed in the AmeriCorps Program.
- No Background Checks or Health Exams required beyond what is required of NHC AmeriCorps Members.