Health Care Navigator - Supportive Services For Veteran Families (ssvf)

Job Objective

Provide services connecting SSVF eligible Veterans who are homeless or at risk of homelessness to VA health care benefits, or community health care when Veterans are ineligible for VA care. Provide case management, care coordination, health education, interdisciplinary collaboration, consultation, quality improvement, and risk management working with the Veteran's primary care provider and the assigned interdisciplinary treatment team.

Essential Functions

This job description should not be interpreted as all inclusive. It is intended to identify the essential functions and requirements of the position. Other job related responsibilities and tasks may be assigned. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential job functions.

• Non-Clinical Assessment: Following intake, engage Veterans in a non-clinical assessment of the Veteran's health/mental health situation, potential barriers to care, causes, and the impact of barriers on the Veteran's ability to access and maintain health care services. Obtain secondary and tertiary information in collaboration with the interdisciplinary team, family members, health care providers, and significant others to develop a comprehensive understanding of the Veteran's health care needs. Ensure that appropriate releases of information are obtained and that confidentiality requirements are observed.
• Health Care Team and Veteran Communication: Work closely with Veterans and assist in communicating Veteran care preferences and personal health goals to health care providers and to facilitate shared decision making of the Veteran's care. Serve as a resource for education and support for Veterans and families, and identify appropriate Veteran-centered supports.
• Community Services, Outreach, and Referrals to Support Veteran's Care Plan: Develop the Veteran's SSVF health care plan with an emphasis on community services, outreach, and referrals needed for the Veteran. Develop the plan in collaboration with the interdisciplinary treatment team, Veteran, family members, and significant others; incorporating measurable goals. Regularly review care plan goals with the Veteran, conduct ongoing non-clinical barrier assessments, and provide resources and referrals needed to support adherence. Evaluate effectiveness of resources and referrals provided and make modifications to ensure provision of high-quality care and interventions. Monitor and document progress and provide updates to the team as appropriate.
• Specialized Case Management and Care Coordination: Provide comprehensive case management and care coordination across episodes of care acting as a health coach by proactively supporting the Veteran to optimize treatment interventions and outcomes. Modify services to meet the Veteran's needs and coordinate services with other organizations/programs to assure provision of complementary and comprehensive services. Represent the program in contacts with other agencies and the public. Coordinate additional supportive services to ensure Veteran and caregivers are linked to supportive services, including but not limited to, housing, financial benefits, and transportation. Coordinate referrals to VA, community health clinics, and other programs needed to ensure access to health care. Follow the care plan to facilitate adherence and collaborate with community providers to maximize use of VA and community resources. Act as an advocate for the client, integrating the Veteran's cultural values into the care plan. Assist Veteran to identify methods to monitor progress toward meeting health goals. Provide ongoing follow-up.
• Health Education: Educate Veterans and caregivers on available services and assist with referrals based on Veterans' preferences. Assist in identifying the Veteran and family's health education needs and provide education services and materials that match the health literacy level of the Veteran. Provide ongoing education support as needed based on identified needs.
• Interdisciplinary Collaboration, Coordination and Consultation: To promote the highest level of quality care, collaborate with the health care provider, interdisciplinary care team, and the SSVF team, regularly consulting on ongoing assessment of Veteran needs. Act within professional boundaries and roles appropriately, respecting the roles of others involved in care and services.
• Risk Management & Infection Control: Complete required training including: Safe from Harm, Blood Borne Pathogens, The Salvation Army's Case Work Certification Program, Confidentiality, Ethics, Suicide Prevention, and all SSVF Health Care Navigator training. Report any accidents or injuries to self or clients and complete appropriate documentation. Follow risk management plan, infection control practices (i.e., hand washing, universal precautions/isolation procedures, and precautions), follow protocols specific to COVID-19 prevention, and all safety protocols vital to staff and Veteran safety.
• Confidentiality, Computer Security, and Ethical Practice: Adhere to ethical standards of practice and principles of confidentiality, informed consent, compliance with relevant laws, and agency policies (e.g., critical incident reporting, HIPPA, Duty to Warn). Ensure client confidentiality is maintained in accordance with established procedures and regulations.
• Continuous Quality Improvement (CQI) and Systems Improvement: Participate in expanding knowledge related to health care navigation with the Veteran population. Collaborate with supervisors to review research-based best practices and make suggestions on improvements to HCN service delivery. Participate in case reviews and progress updates in team meetings. Submit monthly reports as required on activities and unmet needs. Attend in-service and outside trainings as requested. Assure service delivery in compliance with VA-SSVF program regulations, SSVF Program Guide, SSVF policies/procedures, The Salvation Army's policies/procedures, 38 CFR Part 62, and policies/procedures/waivers specific to COVID-19 as instructed by the VA-SSVF Program Office.
• Customer Service: Participate effectively in team meetings, case conferences, and related activities. Collaborate with multidisciplinary team members to enhance coordination of comprehensive Veteran care. Effectively communicate and utilize community agencies to facilitate continuity of care.
• Age, Development, and Cultural Needs of Veteran Clients: Consistent sensitivity to all Veteran's needs concerning age, developmental requirements and culturally related factors and consideration of age-related differences in the provision of care.

Minimum Qualifications

The requirements listed below are representative of the minimal education, experience, certifications, skills, and/or abilities required for this position.

Education: Bachelor's degree required but years of experience noted below may substitute.

Experience: Prior experience performing medically based case management, experience serving homeless population and Veterans preferred, and prefer experience with crisis intervention and community resources.

Certifications/Licenses: None.

Skills/Abilities: Advanced case management skills in a medical or medical case management environment and an ability to function independently while seeking supervisory consultation. Exercise sound judgment and initiative in day to day activities based on expertise accumulated through education, training, experience, and staying abreast of best practice literature. Competent in use of computer technology for documentation, date entry, and virtual technologies. Must concentrate mental and visual attention closely on work for sustained periods, employ critical thinking, and creative problem solving.

Skills/Abilities/Competencies & Key Performance Indicators

These are the skills, abilities, competencies, and key performance indicators that the employee is expected to demonstrate in the performance of their position and which is evaluated annually:

1. Collaboration & Teamwork: Builds good working relationships, collaborates, and cooperates with staff, supervisors, managers, and other organizational departments, outside agencies, and other community partners. Works effectively as a part of a team to achieve organizational and program goals. Shows respect for others and values their contributions. Shares ideas and contributes to greater productivity in meeting shared goals.
2. Attendance & Timeliness: Consistent, good attendance, and punctuality are essential to satisfactory performance of job duties. Demonstrates the ability to prioritize tasks and manage work effectively. Completes work on time and meets deadlines. Responds promptly to supervisory and management requests.
3. Communication: Communicates with co-workers, supervisors, managers, clients, vendors, and community partners in a cooperatively respectful professional manner. Listens effectively to the ideas and perspectives of others to seek understanding. Expresses thoughts and ideas easily in groups, teams, and one on one conversations. Written and verbal communications are professional, clear, concise, and articulate relevant information using Standard English. Ability to communicate using terminology and language unique to The Salvation Army and SSVF program. Demonstrates effective presentation and public speaking skills.
4. Financial Impact: Values, guards, and uses efficiently, the assets and resources of The Salvation Army and the SSVF program, including grant funds. Completes annual fraud prevention training and follows fraud prevention and risk management protocols. Initiated an idea that could be implemented to reduce operational costs/expenses or that could potentially increase revenue for the program or The Salvation Army.
5. Flexibility & Adaptability: Accepts change in a positive manner, recognizing it as a normal part of organizational and program growth. Views change as an opportunity rather than a setback.
6. Initiative: Perceives and proactively recommends improvements or solutions to program processes, problems, or barriers. Respectfully asks appropriate questions regarding organizational and program processes while seeking resolution of issues or concerns. Demonstrates ability and willingness to utilize available training and information sources to find answers and solutions and shares suggestions with