Health Coach

One Brooklyn Health•New York, NY

About The Position

The Health Coach reports to the administrative director and collaborates with a licensed Registered Nurse on the practice’s staff. The role has primary responsibility for implementing a collaborative assessment process for the Health Home At-Risk project and Health Home eligibility; care planning; population health management; coordination of care for patients on the caseload; patient education and advocacy; and regular evaluation of patients on the caseload. The Health Coach uses patient registries and outreach to support chronic disease management, screenings, appointments, referrals, care transitions, and follow-up. The role also supports patient self-management, community workshops and events, and the practice’s performance improvement work. The position requires a high school diploma or GED and experience as an MA/LPN/PCT or other clinical support staff member. Duties involve routine exposure to blood, body fluids, and tissue, as well as sitting, standing, walking, bending, stretching, and potentially assisting with lifting patients or handling heavy weights. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. The job description states that its duties are not exhaustive and may change at the discretion of One Brooklyn Health.

Requirements

High school diploma or GED.
Experience as an MA/LPN/PCT or other clinical support staff member.
Training or knowledge of vital signs; standardized assessments of basic medical and substance use history and symptoms; and Motivational Interviewing, including goal setting.
Experience with public speaking and interviewing.
Ability to work in surroundings with some degree of dust, noise, or similar conditions without undue discomfort.
Ability to hear, talk, walk, stand, bend, and stretch.
Ability to read, write, and interpret documents.
Ability to sit for long periods at a desk to perform job functions and to stand for long periods at a patient bedside or procedural area.
Ability to communicate effectively with patients and/or coworkers.
May be required to handle reasonably heavy weights across distances and assist with lifting patients onto or off exam beds or procedure stations.
Must be trained in and knowledgeable about Kingsbrook/Rutland policies and procedures pertaining to hazardous waste and hazardous materials, and maintain qualifications applicable to assigned work.
Knowledge of all codes and understanding of them.
Duties routinely require exposure to blood, body fluid, and tissue.

Responsibilities

Use registries to identify patients with newly diagnosed, undiagnosed, or poorly controlled chronic conditions and schedule follow-up appointments.
Conduct outreach to patients with overdue screenings or upcoming appointments.
Perform intake and assessment for patients with newly diagnosed or poorly controlled chronic conditions; screen for Health Home eligibility and check Health Home enrollment.
Screen for behavioral health and substance use problems, including depression using PHQ, alcohol abuse using AUDIT, substance abuse using DAST, and smoking status.
Reinforce education provided by a PCP or nurse on chronic disease management, provide self-management tools, and review how to use them.
Establish goals and create a care plan with the patient.
Lead and participate in Diabetes Prevention and self-management workshops.
Organize and participate in community events and fairs.
Work with patients to mitigate the impacts of social factors on health and functional status, for example by arranging transportation.
Conduct a post-visit review of next steps with the patient.
Coordinate care, assist with referral management, and conduct between-visit monitoring and outreach.
Track and follow up on test results to ensure patients and caregivers take appropriate next steps as needed.
Serve as the primary care practice’s first point of contact during post-discharge care transitions from a hospital or emergency department.
Work with the practice’s performance improvement team.
Assist in scheduling huddles and other internal team meetings.
Perform other duties as requested.