Care Advocate for Complex Needs

Job Summary

This role requires delivering comprehensive care and advocating for patients with complex needs.

Responsibilities

• Provide compassionate care options and services to meet the unique needs of each patient.
• Conduct thorough assessments of patients' bio-psycho-social, environmental, vocational, and financial requirements.
• Engage with patients and their families to understand health beliefs and behaviors that impact their well-being.
• Gather information about patients' social support systems and other socioeconomic resources that influence their health outcomes.
• Identify key factors contributing to patients' bio-psychosocial needs and collaborate with healthcare teams to prioritize care plans.
• Work with interdisciplinary teams to develop and implement individualized care plans, focusing on lifestyle modifications, behavioral health interventions, medication management, self-monitoring, and adherence to treatment protocols.
• Regularly follow up with patients to monitor their progress, address emerging issues, and escalate concerns to the care team as needed.
• Support patients with chronic conditions or complex psycho-social issues through regular phone calls and home visits with Medical Social Workers.
• Facilitate seamless transitions between care settings by serving as a liaison and point of contact for patients and their families.
• Empower patients and families to recognize the impact of behavioral health factors on their overall well-being and provide them with relevant education and resources to promote healthy choices.
• Disseminate accurate health information and materials to reinforce knowledge gained during clinic visits.
• Organize and coordinate support groups, workshops, and community outreach programs to foster collaboration and education.
• Promote quality improvement initiatives and adhere to established safety guidelines and best practices.
• Stay informed about industry developments through ongoing training and professional development opportunities.

Requirements