Outreach Care Coordinator

SUMMARY

The Outreach Care Coordinator will support and promote LACHC’s mission to follow Christ by loving and serving our neighbors through comprehensive, quality healthcare. The OCC will serve as a Lead Care Manager for the Medi-Cal Enhanced Care Management (ECM) program. As Lead Care Manager, the OCC is responsible for maintaining all biopsychosocial care management services for enrolled patients, including strategies to address medical, behavioral, social, and long-term services and supports needs.

In addition to individual care coordination, the OCC engages in initiatives designed to promote the organization and its services to the community and promote new patient outreach and enrollment.

• Assess, organize, and initiate partnership activities to enhance services provided to current and potential patients.
• Represent the organization at community and faith-based events and activities.
• Attend community meetings, such as coalition and advocacy meetings, community updates, case conferencing, etc.
• Build and maintain positive working relationships with community partners.
• Conduct street outreach on a weekly basis.
• Use effective communication skills such as active and reflective listening to build rapport with vulnerable and difficult-to-engage clients.
• Use evidenced based outreach strategies to locate clients and link them to care.
• Motivate patients to be active and engaged participants in their health.
• Assist patients with scheduling appointments and assisting with completion of registration paperwork for patient care.
• Supply or obtain necessary items, such as hygiene kits, clothing, blankets, etc.
• Assess supply needs for patient population and strategize resolution.
• Organize, promote, and track in-kind donation initiatives for Care Coordination.
• Utilize, maintain, and update LACHC resource guide as changes occur and keep resource information on-hand to give to clients for all applicable resources.
• Conduct outreach and enrollment calls to eligible patients for ECM.
• Ability to work in groups as well as self-guided, independent outreach and coordination.
• Demonstrable experience and understanding of coalition building and nonprofit advocacy, engagement with relevant initiatives, and briefings to departmental leadership.

• Maintain a patient caseload consisting of ECM participants.
• Apply evidence-based interventions, such as motivational interviewing and harm reduction, to decrease or prevent complications and optimize patient well-being.
• Promote self-management skills for each client to achieve self-directed, individualized health goals that promote recovery, improved functional and/or health status, and/or prevent or slow declines in functioning.
• Provide culturally appropriate health education on condition-related topics, such as nutrition, disease management, and treatment compliance.

• Monitor and encourage treatment plan adherence.
• Manage referrals, coordination, and follow-up for services and supports.
• Ensure appropriate care at level of care transitions by providing evidence-based transition planning.
• Assisting clients with linkage and access to vital and appropriate resources per eligibility status, such as:
  • Housing;
  • Substance abuse treatment;
  • Mental health care; and
  • Public benefits.
  ▪ Assist with documentation and identification needs. ▪ Assist clients with locating and obtaining transportation to/from appropriate medical and/or social service appointments.
• Expertise in administering structured assessments, including assessments on Social Determinants of Health, to gather, track, and assess client progress.
• Provide immediate assistance to patients as needed, including locating emergency shelter, food resources, etc.
• Apply Harm Reduction strategies to engage with clients, including participation and certification in Narcan training.
• Provide accompaniment services to clients as needed, determined by patient assessment and interviews.
• Utilize strengths-based, solution-focused strategies to assist patients.
• Create SMART goals in collaboration with patients.
• Other duties as assigned.

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