Health Coach

One Brooklyn Health•New York, NY

About The Position

The Health Coach will report to the administrative director and collaborates with licensed Registered Nurse on the practice's staff. Will have primary responsibility for implementing a collaborative process of assessment for the Health Home At-Risk project and Health Home eligibility, care planning, facilitation of population health management, coordination of care for patients on caseload, patient education, patient advocacy, and regular evaluation of patients on caseload.

Requirements

High School Diploma or GED required.
MA/LPN/PCT, or other clinical support staff member.
Training or knowledge of vital signs, the use of 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 degree of dust, noise, etc. 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 of time at desk to perform job functions.
Ability to stand for long periods of time at required patient bedside and/or procedural areas.
Ability to communicate effectively with patients and/or co-workers.
May be required to handle reasonably heavy weights across distances.
May be required to handle/ assist in lifting patients onto/out of exam beds/procedure stations.
Must be trained in and knowledgeable of all Kingsbrook/Rutland policies and procedures pertaining to hazardous waste and hazardous materials and maintain qualifications applicable to assigned work.
Knowledge of all codes and demonstrate understanding
Duties performed routinely require exposure to blood, body fluid and tissue.

Responsibilities

Uses registries to identify patients with newly diagnosed, undiagnosed or poorly controlled chronic conditions and schedules follow-up appointments.
Conducts outreach to patients with overdue screenings or upcoming appointments.
Performs intake and assessment of patients with newly diagnosed or poorly controlled chronic conditions, screens for Health Home eligibility, and checks Health Home enrollment.
Screens for behavioral health and substance use problems, including depression (PHQ), alcohol abuse (AUDIT), substance abuse (DAST) and smoking status.
Reinforces education provided by PCP or nurse on management of the chronic disease, provides self-management tools, and reviews how to use those tools.
Establishes goals and creates a care plan with the patient.
Lead and participate in Diabetes Prevention and self management workshops
Organize and participate in community events and fairs
Works with patient to mitigate impacts of social factors on health and functional status, e.g. by arranging transportation for patients.
Conducts post-visit review of next steps with patient.
Coordinates care, assists with referral management, and conducts between-visit monitoring &outreach.
Tracks and follows up on test results to ensure patient and caregiver take appropriate next steps as needed.
Serves as primary care practice's first point of contact during post-discharge care transition from hospital or emergency department.
Works with practice's performance improvement team.
Assists in scheduling huddles and other internal team meetings.
All other duties as requested.