Patient Healthcare Navigator - August 2023

The UPMC St. Margaret Family Health Centers of Lawrenceville is in an impoverished Allegheny County community and is within walking distance of many who cannot afford transportation and would not seek health care at all if it were not for the proximity of their homes. According to the U.S. Census data, the median age of people in Lawrenceville is 34. This is worth noting because Allegheny County is traditionally thought of as a very aged population. However, in Lawrenceville, there exists a younger community comparatively. Twenty-five percent of annual visits to Lawrenceville Family Health Center are people under 18 years of age. The median family income is only $21,932.  13 percent of families and people have an annual income below the poverty level. Of households headed by women with children under 18, a striking 80% have income below the poverty level.  Thirty percent of residents are black or a combination (compared to greater Pittsburgh ~ 13%) and 11% of the households speak a language other than English. This data reflects the wonderful diversity enjoyed in this area.  

In this setting, the health center provides over 10,000 patient care visits per year. Despite a concentration of medical services in Pittsburgh, families lack financial resources, transportation, and health literacy to address their preventive care needs and the adoption of a healthy lifestyle. 15% of patients do not have a high school diploma and nearly the same number of households do not identify English as their first language. With low health literacy, language barriers, and financial concerns, our patients benefit from having a patient navigator to help them access health services, and better understand strategies for health and wellness. 

Responsibilities will include:  

• Keeping a population health registry for preventive care  
• Educating patients regarding needed preventive care screenings  
• Educating patients about self-management of diabetes, hypertension and coronary artery disease that focuses on life-style changes: diet, nutrition and exercise as well as appropriate tests and studies (ie eye exams)  
• Healthcare navigation assistance for health center patients to ensure that connection with the correct provider and follow up  
• Creating and maintaining patient databases, resource listings with contact information
• Creating and sending appointment reminders for patients that frequently miss scheduled PCP and specialist appointments.  
• Attending weekly multidisciplinary team meetings to case manage challenging patient needs  
• Attending weekly MAT (medication assisted treatment) team meetings set up to case manage our patients on various treatments for alcohol and opiate addiction  
• Attending monthly Integrated Behavioral Health team meetings  
• Evaluate and initiate appropriate referrals for assistance through County, State, and Federal programs when needed  

• Assisting in care coordination and resource referrals
• Tracking referrals and closing the referral loop
• Evaluating referral charts and obtaining reports
• Conducting outreach to patients via phone/letters
• Linking patients to care by scheduling appointments

• Self-starter
• Flexible
• Multi-tasker; able to balance
• Detail-oriented
• Community engagement/outreach skills
• ability to take initiative

• 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

• Member uses initiative in carrying out recurring assignments following set procedures, independently.
• The supervisor assigns service activities in terms of project objectives and basic priorities and is available for consultation in resolving controversial issues.
• assists with project due for the week

• The Member independently plans and carries out the projects and selects the approaches and methods to be used in solving problems.

• Detailed guidelines exist, including regulations and directives, handbooks, precedents, industry standards and files of previous projects.
• Guidelines are generally applicable, but the Member independently makes adaptations in dealing with problems and unusual situations.

• Member has to develop, analyze, or evaluate information before the service position can progress.
• In making decisions, the Member is often required to depart from past approaches and to extend traditional techniques.

• Personal vehicle required

In addition to NHC Standard Checks, all NHC Pittsburgh members are required to complete and pass criminal history checks for Great Lakes Behavioral Research Institute/Diversified Care Management (DCM). Great Lakes/DCM is a third party vendor contracted with the Allegheny County Health Department (operating site for NHC Pittsburgh) to distribute NHC Pittsburgh member stipends. NHC Pittsburgh members are onboarded to Great Lakes/DCM system only when the checks have been completed and the member has passed those checks.  Along with these checks, ALL NHC Pittsburgh Members Are Required to be Vaccinated against COVID-19. 

The checks that all NHC Pittsburgh members would be required to complete and pass for Great Lakes/DCM are the following: 1) Act 33 (Pennsylvania Child Abuse Clearance), 2) National Sex Offender Registry Clearance,  3) Act 34 (Pennsylvania Criminal History Clearance, and 4) Act 73 (FBI Criminal History Clearance - ONLY completed via Identogo PA).

NHC members do not have to pay for the completion of these checks. Great Lakes/DCM will distribute payment codes for the Act 33 (Pennsylvania Child Abuse Clearance) and Act 73 (FBI Criminal History Clearance which is conducted through Identogo PA ( PA FBI fingerprinting agency). The National Sex Offender Registry Clearance and Act 34 (Pennsylvania Criminal History Clearance) will be completed by Great Lakes/DCM upon receiving requested information that members will be asked to submit.