Integrative Services and Senior Patient Navigator

The member will work with the Integrative Services AND the Social Services teams.

Integrative Services:
Our center offers a diverse list of programs that patients can be referred to by current providers within any department or choose a la carte based on their own interests and health needs. Although these services are offered within one building, many patients are not aware of the vast array of programs available, how to get involved or who to contact.  Programs such as nutrition education, cooking classes, fitness and exercise classes, yoga, meditation, creative arts therapies groups, and other health education classes are offered. The core of the member’s responsibilities is to engage, inform, orient, link and register new and existing patients and community members to the myriad of integrated services and provide individual consults as needed to better support referrals and increase access to programs.    By decreasing barriers and supporting recruitment and retention and ultimately enhancing the quality of patient care, the center can better meet the needs of such individuals. 

The member will support in-reach and outreach efforts to promote the above-mentioned programs. Once patients have been linked and registered in a program the member responsibilities include but are not limited to organizing and promoting information sessions regarding specific programs, and making reminder calls for said classes and events. Additionally, the member will make the patient program calendars as well as communicating this information to appropriate departments.  Other duties to enhance patient recruitment and retention could include administering patient satisfaction surveys, making follow-up phone calls to all new patients seen within a week, with an emphasis on patient recruitment and outreach.  The member will be present in all community advisory councils, primary care huddles and other Department meetings as needed to ensure information flows from one team to the next and that programs are not offered in a silo rather there is continuity in open communication across departments.

Social Services:

This team supports patients and their families obtaining the social serviced required to meet their unique needs. The member will support seniors.

Member will assist patients who are 50 and over remove barriers and organize end of life planning practices. Connecting patient with our legal partnership to create wills and engage power of attorney if needed. The member will assist seniors and their families with engaging supports to keep seniors in their homes. Member will assess food insecurity in senior patients and connect them with appropriate resources such as the 11th street pantry, meals on wheels, mom’s meals, manna and other food resources. Member will assist senior patients and families in navigating insurance questions and issues. Member will specifically focus on those have Medicare advantage plans, Medicare with community health choices and those patients who are new to Medicare and have questions while reaching out to all patients3 months prior to their 65th birthday.

• Completing and submitting patient applications for social services and medication assistance programs
• Following-up with patients to ensure documentation is completed
• Coordinating with other programs to provide health classes
• Recruiting clients to participate in health classes
• Conducting outreach to patients via phone/letters
• Attending Community Advisory meetings.
• Facilitating at least one Undoing Racism meeting and Conducting at least one Trauma Informed Care workshop.
• Providing support to patients in program engagement.
• Supporting seniors in end of life planning, food insecurity, and insurance navigation