Community Health Navigator

Mosaic Primary Care Network•Calgary, AB

20h•CA$20 - CA$27•Hybrid

About The Position

The Community Health Navigator (CHN) works with Mosaic PCN patients to help them address the challenges they may face with multiple chronic conditions in accessing necessary health services. Using non-medical community members, the CHN focuses on promoting positive self-management behaviour, assisting patients in achieving care plan goals, facilitating health system navigation, connecting patients to community resources, and offering culturally appropriate support and information to optimize overall health outcomes.

Requirements

At least 3 years’ community involvement work (formal or informal) that reflects strong ties to local community.
Experience working with different socio-economic groups and backgrounds.
Must have strong desire to help and connect patients with the community.
Strong community links within the Mosaic PCN catchment area (NE and SE)
Willingness to learn health care terminology.
Understanding of the health care and social resources available in Calgary.
Multi-cultural competence.
Organizational and prioritization skills.
Ability to teach others.
Strong communication and interpersonal skills.
Problem solving skills.
Ability to develop strong relationships with internal and external parties.
Ability to discuss sensitive topics with patients and maintain confidentiality.

Nice To Haves

Multi-lingual.
Shared experience with targeted patient population.
Familiarity with medical terminology.

Responsibilities

Support patient attachment through regular, patient-centered follow-up, including home visits to engage and empower patients.
Identify appropriate and credible resources for patient needs taking into consideration culture, language, reading level, and health literacy.
Coordinate patient care between multiple health and social providers typically within the Mosaic PCN catchment area and leverage Mosaic PCN programs and services.
Monitor attendance, conduct reminder and follow-up calls, and facilitate transportation to and from scheduled appointments, as necessary.
Taking into account each patient’s values, preferences and circumstances, support the development of patient-centered goals.
Demonstrate responsiveness to patient needs within scope of practice and professional boundaries.
Encourage active communication between patients/families and health care providers to optimize patient outcomes.
Provide appropriate patient education in the community.
Support patient self-management techniques.
Teach patients the health care payment structure, financing, where to refer patients to answers regarding insurance coverage and financial assistance.
Use goal setting and motivational interviewing techniques in difficult conversations.
Provide and/or coordinate interpretation and translation services with patients, if applicable.
Integrate with the clinic team and serve as liaisons between clinics and patients.
Understand the goals related to Mosaic PCN health outcomes and support the implementation of plans.
Regularly check in with patients to verify adherence to care plans.
Provide timely follow-up for physicians and multidisciplinary team on the patients’ status.
Maintain timely and accurate records in EMR capturing patient records, interactions, barriers and other pertinent information.
Liaise closely with community partners and members to understand and address barriers for access to care.
Promote CHN role, responsibilities, and value to patients, providers, and the larger community.
Participate in community activities to build trusting relationships across a broad range of socioeconomic and cultural backgrounds.
Leverage community resources to assist patients to create ties to the community.
Ensures success of the program through the identification of key successes and challenges and supporting the development of innovative approaches to leverage strengths in addressing challenges.
Identifies and works to achieve own professional development needs which support goals set in performance reviews.
Other responsibilities as required.