At DAP Health, we are committed to transforming lives and advancing health equity for all. As a leading nonprofit health care provider, we deliver compassionate, high-quality care to the diverse communities of the Coachella Valley and San Diego County. Our comprehensive services range from primary care to mental health, wellness programs, and beyond, with a focus on those who are most vulnerable. Joining our team means becoming part of a passionate, innovative organization dedicated to making a meaningful impact in the lives of those we serve. If you're looking for a dynamic and purpose-driven environment, we invite you to explore the opportunity to contribute to our mission.
Job Summary:
Participate as an active dedicated member in the Behavioral Health Integration and Complex Care Initiative (BHICCI) focusing on populations with complex needs. Assist in integration of whole-person care and patient navigation throughout the healthcare system. Be proactive in the integration of Behavioral Health services into the Primary Care setting. Responsible for navigating the essential components of Health Services in the patient’s home and community for the patient as needed. Is responsible to be a liaison between the Patient, Primary Care/Specialty Providers, Behavioral Health Providers and community resources. Is responsible for updates in scheduling follow-up appointments and assisting patients in navigating care between Behavioral Health, Primary Care and Specialty appointments. Responsible for integrating clinical and community-based settings to help patients achieve optimal health and well-being while encouraging appropriate utilization of outpatient and inpatient services. Upholds the importance of providing culturally appropriate interventions (religion, poverty, relationship status, education language, etc., crucial components to consider) and deliver these in a sensitive manner that upholds person’s dignity.
Supervisory Responsibilities: N/A
Location: This position will be working in Palm Springs, CA.
Essential Duties and Responsibilities:
Clinical Functions:
- Understands and assists as needed with maintaining current information in the EHS, Reporting Registry and i2i referral tracking systems.
- Follows all program protocols, maintains personal and patient safety, and documents in an accurate and timely manner.
- Ensures appropriate releases of information are obtained to facilitate record sharing between providers and facilities.
- Establishes a trusting and open relationship with complex patients empaneled to the BHICCI program. Primarily interacts with patients in the community and their homes.
- Conducts a baseline needs assessment and works with the patient and medical home team to create a comprehensive care plan.
- Motivates and activates the patient to set and achieve personal goals. Communicates those goals and progress on those goals to referring providers. Adjusts care plan and goals as necessary to achieve optimal health and wellbeing.
- Provides health education and counseling around disease management, medication adherence, mental health, addiction, and self-care. Supports the patient’s understanding of diagnostic and therapeutic plans.
- Performs medication reviews in the patient homes and informs the clinical team of medication dosing/timing discrepancies. Encourages medication adherence and facilitates communication with the care team around medication concerns.
- Enhances patient’s health literacy and ability to self-manage and cope with physical disease, addiction, or mental illness.
- Assists patient with navigating the medical, social service, and behavioral health systems. Facilitates timely referrals to quality service providers and accompanies patients to those appointments as necessary.
- Assists Medical Case Workers, social workers, and community-based social service personnel in addressing “social determinants of health” for patients. Such activities include assisting the patient in obtaining housing, financial assistance, legal support, and social support.
- Accompanies the patient to critical medical and social service appointments and ensures that the patient’s needs and context are fully understood by service providers. Ensures that the patient understands the treatment or service recommendations and assists the patient in following through on those recommendations.
- Assists the patient around “transitions of care” as patient transfers from one care setting to another. Conducts home visits within 72 hours of emergency room visits or hospitalizations to assess patient status and ensure appropriate follow up with clinicians.
- Advocates for patient within clinic and community-based settings to help patient achieve health and life goals
- Helps team to build organizational relationships with community-based organizations.
- Develops relationships with health care team members, resources providers, and patient’s families.
- Participates in the systematic population/caseload review and works with other members of the Care Management Team to facilitate health care, promote patient health and comfort, and support patients while they learn to self-navigate.
- Provides quality care to patients of Dap Health, within the scope of practice outlined by state or federal law.
- Delivers care in accordance with established standard of care and accepted community standards.
- Understands the organizations commitment to provide high quality integrated patient care.
- Promotes a patient centered environment.
- Actively participates in all mandatory program trainings as well as regularly scheduled department meetings.
Administrative Functions:
- Coordinates length and frequency of patient sessions.
- Contact patient for appointment scheduling.
- Confirm appointment in advance with patient.
- Monitor patient compliance and report to patient care team.
- Attempt to reschedule ‘Cancellations’.
- Schedule follow-up appointments according to Care Team, Provider and Patients’ agreement
- Medical Records Maintenance duties include :
- Maintain a medical record for each BHICCI patient.
- Records shall be complete, orderly, up to date, and correctly filed
- Track BHICCI patient population data in the medical record and assists in duplication of the data in the registry.
- Obtain appropriate confidentiality release from patient when warranted.
- Obtain records of previous mental/behavioral health treatment as requested by providers.
- Verify signatures and dates on all forms in the medical record.
