Community Health Worker​/RAP

Overview

JOB PURPOSE:

To provide linkage and retention of patients in HIV primary care, identify patients lost to care, and develop a comprehensive approach to assessing and assisting patients at risk for non-compliance, non-retention, and non-adherence to HIV care and treatment. Additionally, this position will focus on expanding the PrEP Program through providing patient education, engagement, navigation, retention, and adherence counseling services.

• Result #1:
  To identify patients eligible for services per RAP Program Standards and document required information in AIRS, Caseload, and the Electronic Medical Record system:
• Conducting oneself in a professional, courteous, and friendly manner.
• Occasionally greeting PPC patients when they show up in the reception area and inquire about needs other than clinical expectations.
• To verify that prospective HIV patients are newly diagnosed, not virally suppressed, residents of New York State, and meet income guidelines.
• Document patient enrollment information in AIRS and the Electronic Medical Record system (eCW) per RAP Program Standards.
• Collaborate with PPC Providers and nurses to support the continuum of care to the benefit of patients

• Result #2:
  Clinical Adherence Management and Direct Client Services:
• Provide immediate and short-term support to patients who may experience mental, physical, emotional, and behavioral distress.
• To conduct adherence assessments for retention and adherence barriers (housing, social support, and mental health) at the time of enrollment.
• Develop and implement a strength-based, individualized treatment adherence service plan within 30 days of the patients’ initial PPC appointment based on the patients’ needs and goals.
• To provide individual treatment adherence counseling and monitoring of patients enrolled in the RAP Program.
• The Community Health Worker/RAP will case conference with each patient quarterly, addressing progress in achieving goals, medication, and viral load status, and discussing strategies to address identified barriers.
• Use evidence-based retention and medication adherence interventions.

• Result #3:
  Care Coordination and Multidisciplinary Integration:
• Utilize a multidisciplinary team approach with the entire PPC department (physicians, nurses, case managers, and behavioral health staff) to ensure that patients are adherent.
• Case conference with each patient quarterly to address progress, medication status, and strategies to address barriers.
• Utilize a multidisciplinary team approach with the entire PPC department to ensure patient adherence.
• Collaborate with case management, pharmacy, substance abuse treatment, and mental health services to improve retention and medical outcomes.
• Conduct re-engagement efforts for patients who have not had blood work in six months or attended a doctor’s appointment in over a year.

• Result #4:
  Program Administration and Outcomes Monitoring:
• Re-evaluate patients’ service plans and assessments every three months and update them as necessary in AIR and the Electronic Medical Record system.
• Collaborate with case management, pharmacy, substance abuse treatment, mental health, and other services to improve retention, adherence, and medical outcomes for PLWHA.
• Facilitate home visits to the patient’s home to increase treatment adherence goals and outcomes.
• To conduct re-engagement efforts for those patients who have not had their blood work in at least six months or who have not attended a doctor’s appointment in more than a year.
• Work with the Program Manager to address Quality Improvement activities.
• Report monthly on the outcomes, performance measures, and quality improvement activities.
• Promote medication adherence through regular check-ins, skills-building, and client-centered motivational interviewing techniques.
• To document case closure for those patients who have maintained viral load suppression for two consecutive viral load tests, at least ninety days apart or have left the program for another reason (lost to care or transfer out of the RAP program)
• Perform other duties as assigned.

EDUCATION AND EXPERIENCE

REQUIRED:

• B.A. or…