Patient Healthcare Navigator

Position Status

Full

Site

Pittsburgh

NHC Position Type

Patient Navigator

Position Summary

The UPMC St. Margaret New Kensington Family Health Center is an underserved community serving residents of Allegheny and Westmoreland counties since 2001. The New Kensington Family Health Center 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 New Kensington is 46.8 years and 15.8 percent of people under 65 are disabled. This is worth noting because of the Family Health Centers proximity to public housing and five senior high-rise buildings.  The median family income is only $26,793.  23 percent of families and people have an annual income below the poverty level. 8.3 percent of residents under 65 do not have health insurance.  14.3 percent of residents are black or a combination. 6.2 percent speak a language other than English at home.  This data reflects the wonderful diversity enjoyed in this area.  

The health center offers high-quality family health care, integrated behavioral health and community partnerships to medically underserved patients. We had 9100 patient visits last year. Over 50% of our patients qualify for Medicare or Medicaid services.  In recent years there has been a decline in access to services in this area. 

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

  • Screening patients for health concerns and eligibility 
  • Following-up with patients to ensure documentation is completed
  • Providing education on how to complete paperwork 
  • Brief health education to patients
  • Tracking, enrolling, and surveying patients for improvement
  • Attending meetings and patient huddles
  • Conducting phone outreach as assigned by leadership
  • Assisting in care coordination and resource referrals
  • Conducting outreach to patients via phone/letters
  • Linking patients to care by scheduling appointments
  • Researching and designing monthly education displays
  • Collaborating with leadership to meet needs of materials
  • Interacting with patients to complete quality reviews
  • Conducting extensive and continuous research on social services
  • Creating social service resource guides and lists for clients
  • Developing assessment tools to track patient improvement
  • Coordinating for resource distribution with other programs
  • Finding additional community resources and programs for patients

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
  • Organized; sound organizational skills
  • Good telephone skills
  • Knowledge of health records
  • Flexible
  • Persistent
  • Start projects independently 

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.
  • The supervisor assigns service activities in terms of project objectives and basic priorities and is available for consultation in resolving controversial issues.

Review

  • Completed projects are reviewed very generally to determine that objectives have been met and are in compliance with policies and regulations.

Guidelines

  • 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

  • In making decisions, the Member is often required to depart from past approaches and to extend traditional techniques.
  • The Member must develop new techniques, methods, or approaches to complete service position assignments.

Purpose and Impact of Service Position Assignments

  • Member provides timely services of a personal nature to others.
  • Member’s service position impacts on the adequacy of research conclusions.
  • The service position product or service affects the accuracy, reliability, or acceptability of further processes or services.
  • The service position product or service affects the design or operation of systems, programs, or equipment.
  • The service position product or services affect the social, physical, and economic well-being of a substantial number of people on an ongoing basis.
  • The member is required to investigate or analyze a variety of unusual conditions, problems, or questions.

Nature of Contacts

  • Community Organizations

Purpose of Contacts

  • To give or exchange information

Special Considerations

  • Special safety regulations or precautions that must be observed

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.