Patient Healthcare Navigator

Position Status

Open

Site

Pittsburgh

NHC Position Type

Patient Navigator

Position Summary

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. 

The NHC member will focus on tracking and acting as a patient navigator for patients who are identified as being part of a high-risk group: (1) patients with chronic medical conditions related to obesity (diabetes, hypertension and coronary artery disease), and (2) patients currently under addiction treatment or history of addiction and (3) patients in need of preventive health screenings. 

NHC will assist identified patients by: 

  • Assisting patients to make and keep appointments for preventive health screenings, referrals and appointments with PCP 
  • Enhancing communication with primary care physician and Integrated behavioral health team 
  • Facilitating communication with primary care physician and medication assisted treatment (MAT) team 
  • Phone outreach to patients and community agencies 

Addressing preventive care through population health reports 

  • Review quarterly reports, organize and update information 
  • Outreach to patients to schedule appointments for preventive care 
  • Providing education about preventive health care services 
  • Making referrals for basic needs such as food and other support services 
  • Assisting patients in navigating the healthcare system: e.g. making and keeping appointments, scheduling needed tests, and following up with specialists 
  • Communication with PCPs regarding outstanding care needed and obtaining necessary orders for preventive care tests 

Patient navigation requires the following skills and activities as well: 

  • Outreach and partnering with community agencies to provide support resources for patients 
  • Education of patients so they understand their medical conditions and why further testing and follow up is needed 
  • Problem solving skills- being able to identify barriers to care, both emotional and socioeconomic 
  • Providing emotional support to patients 

Responsibilities will include: 

  1. Keeping a population health registry for preventive care 
  1. Educating patients regarding needed preventive care screenings 
  1. 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) 
  1. Healthcare navigation assistance for health center patients to ensure that connection with the correct provider and follow up 
  1. Creating and maintaining patient databases, resource listings with contact information
  2. Creating and sending appointment reminders for patients that frequently miss scheduled PCP and specialist appointments. 
  1. Attending weekly multidisciplinary team meetings to case manage challenging patient needs 
  2. Attending weekly MAT (medication assisted treatment) team meetings set up to case manage our patients on various treatments for alcohol and opiate addiction 
  1. Attending monthly Integrated Behavioral Health team meetings 
  2. Evaluate and initiate appropriate referrals for assistance through County, State, and Federal programs when needed 

NHC member will work in a non-clinical role, the staff members of the health center are clinical in their job descriptions. The NHC member will assume the responsibilities of a patient health care navigator. The family health center does not currently have nor previously had this type of position as an employee. The employees of the health center are required to have special training as a medical assistant, registered nurse, license social worker, licensed professional counselor, resident, pharmacist, physician (MD or DO). The NHC member does not have these licenses or meet this level of educational requirement therefore they are unable to function in these job roles. The duties and tasks that will be assigned to the NHC member will be new activities that are not currently being completed by a staff member and they will be non-essential in nature so that when NHC member’s term expires patient safety will not be compromised. Care will be taken to ensure that systems of tracking and follow up of patients can be sustainable for future AmeriCorp members. The Family Health Center confirms that our NHC member’s position will not violate the supplementation requirements of AmeriCorps Program. 

Major Duties and Responsibilities

  • Brief health education to patients
  • Coordinating with other programs to provide health classes
  • Requesting medication refills for patients already enrolled
  • Attending meetings and patient huddles
  • Conducting phone outreach as assigned by leadership
  • 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
  • Collaborating with leadership to meet needs of materials
  • Developing assessment tools to track patient improvement
  • Coordinating for resource distribution with other programs
  • Scheduling and coordinating communication for outreach visits 
  • Assessing community data to locate areas that would benefit from community health screenings and referrals 
  • Finding additional community resources and programs for patients
  • Coordinating patient care with the physicians through in-person or EHR communication .

Characteristics of an Ideal Candidate

  • Comfortable with diversity
  • Basic knowledge of medical terminology
  • Proficient computer and data entry skills (e.g. Microsoft Excel)
  • Multi-tasker; ability to balance
  • Self-manager
  • Good communication skills
  • Outgoing
  • Independent
  • Open-minded
  • Non-judgemental
  • Takes initiative
  • Comfortable in fast-paced environment
  • Organized; sound organizational skills
  • Good customer service
  • Good telephone skills
  • Flexible
  • Problem solving skills

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

  • Member uses initiative in carrying out recurring assignments following set procedures, independently.
  • The supervisor assigns service activities, advises on changes in procedures, and is available for assistance when required.

Review

  • The service activities are reviewed for accuracy through spot checks, through complaints from customers, and through observation of the Member at service.
  • The Member independently plans and carries out the projects and selects the approaches and methods to be used in solving problems.

Guidelines

  • 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 must use considerable judgment in adapting current or developing new guidance.

Complexity

  • 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.

Purpose and Impact of Service Position Assignments

  • Service position assignments involve a variety of conventional problems, questions, or situations that conform to established criteria.
  • The service position product or services affect the social, physical, and economic well-being of a substantial number of people on an ongoing basis.

Nature of Contacts

  • Clients

Special Considerations

  • Special dress code
  • Special safety regulations or precautions that must be observed
  • Criminal history check requirements beyond those required by National Health Corps
  • In the space below, provide additional information or explanations.:
  • Business casual dress

Criminal History Check Requirements Beyond NHC Standard Checks

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.