LGBT Care Coordinator

Trillium Health is a leader in HIV/AIDS care in Rochester and the Finger Lakes. We are expanding our mission to address the social and physical needs of increasing numbers of individuals beyond the HIV-positive community, having developed a successful practice aimed at the LGBT (lesbian, gay, bisexual, transgender) community and now looking to bring our model of care to individuals from all backgrounds who want to experience health care that is comprehensive in scope, customized to their particular needs, and available all under one roof.

If you are interested in becoming part of a growing community health organization, Trillium Health may be the organization for you.

LGBT Care Coordinator

Purpose: To empower eligible patients to improve their quality of life based on priorities and goals set by the individual. Coordinate services with patients by providing support and assistance with navigating systems through collaboration with our multidisciplinary team and community professionals. Work in a proactive manner to limit the need for crisis intervention and to promote independence. To provide the timely, high quality services that will assist in reducing avoidable health care costs and improved patient outcomes by providing support, education, outreach and engagement activities.

Detail of Key Job Responsibility Areas

Care Management

• Provide care management services to LGBT patients that are patient-centered, quality-driven and culturally appropriate in compliance with agency policies and/or funder requirements.
• Assist assigned patients in the reduction of negative health outcomes and avoidable health care cost; specifically focusing on one or more of the following:
  • reducing preventable hospital admissions/readmissions
  • decreasing avoidable emergency room visits
  • improving access to care & continuity of care (ex. follow-up of tests and referrals)
  • Improve patterns of care utilization, including promoting adherence/compliance with medical recommendations
  • enacting behavioral change(s) to improve overall health
• Assist patients in the successful management of all aspects of their care. To do this, the following steps will be taken:
  • Complete initial and ongoing assessment of the individualized needs of assigned patients
  • Determine level of care/support best suited to supporting patient success.
  • Create, document, execute, monitor and update an individualized plan of care for each patient that incorporates a holistic array of health goals/needs that are clearly identified, with timelines, and includes interventions that will produce positive outcomes
  • This plan must be patient-centered and created in partnership with the patient; and should be informed by the input of all relevant members of treatment team including the patient, care provider, care manager and other connected social &/or support services
  • At periodic re-assessments, make indicated adjustments to plan based on patient’s identified needs/desires.
• Provide on-call services to patient/client when assigned.
• Coordinate and provide access to preventive and health promotion and/or other ancillary services and community resources as needed; including mental health and substance use services.
• Promote patient health outcomes through coordination of each patient’s treatment team by
  • Building relationships with patient and with all involved service providers.
  • Coordinating and participating in regular case review meetings that include all members of the interdisciplinary team
• Demonstrate the ability to use the health information technology system to coordinate and link services
• Identify available community-based resources and actively manage appropriate referrals, access, engagement, follow-up and coordination of services
• Maintain comprehensive and accurate written documentation of all patient interactions.
• Demonstrate developing knowledge of community resources.
• Adhere to all government, funder, agency and department regulations

Linkage, Engagement & Retention

• Link hard-to-reach and/or lost-to-care patients to needed services by providing specific outreach services to them.
  • Outreach services may include telephone and/or in-person contact in community settings; and home visits and hospital visits to meet with patients & approved collaterals when appropriate.
• When outreach services identify barriers/needs, oversee the engagement of steps to address them including: coordinating transportation for patients, escorting them to and from appointments, and identifying other community resources to reduce barriers.
• Demonstrate developing knowledge of community resources.
• Participate, as directed, in ongoing outreach services, both in-person and online/social media, conducted through the Community Health Initiatives team; specifically focusing on outreach activities that target LGBT community members and venues with the goal of recruiting and retaining them in high quality ongoing medical care.
• As part of the LGBT Health team, participate in the creation of health messaging targeting LGBT individuals; the dissemination of such materials through the use of social marketing technologies, print & electronic materials to be distributed in community venues and in both LGBT and mainstream press.
• Participate in the ongoing use and maintenance of program-specific social media including agency/program website and social media platforms.

Advocacy & Direct Patient Services

• Act as an advocate for both individual patients and for the LGBT community around issues of access and cultural appropriateness of the care they receive.
• Promote patient access to appropriate internal agency services including, but not limited to: support groups, housing services, daily bread, behavioral wellness, substance use treatment, and medical care.
• Orient patients to services available within the agency and to the mission at Trillium Health.
• Advocate for patient access of entitlement programs, treatment facilities, and other needed community services.
• Demonstrate developing knowledge of HIV/AIDS, STD and LGBT-related issues.
• Participate with the CHI team in the development and delivery of HIV, STD &/or LGBT Health curricula and training(s) directed at the general community and present /future healthcare & human service providers in order to expand the array of culturally appropriate services available to LGBT communities.
• Provide HIV/STD Counseling and Testing as scheduled.
• As needed, participate in the delivery of structured interventions including DEBIs specifically aimed at decreasing risk and/or improving health outcomes for LGBT populations.

Miscellaneous

• Transport clients to services within Trillium Health’s service area in personal vehicle as required.
• Demonstrate developing knowledge of HIV/AIDS and related issues.
• Requires the ability to relate to people of diverse backgrounds, cultures, races, sexual orientations and gender identities or expression.
• Responsible for maintaining confidentiality of all patients, clients, proprietary, and protected information.
• Must be proficient in Microsoft Office; Word, Excel, Outlook and Explorer and have the ability to learn and navigate the HIT systems used.
• Excellent organizational and time management skills required.
• Must have a reliable vehicle and meet the agency driving policy requirements for this position, including a valid NYS driver’s license and proof of required automobile insurance.
• Employees are accountable for meeting performance standards of their departments. They participate in compliance audits and quality improvement plans.
• Other duties as assigned.

Qualifications

Bachelor’s degree in health, human or education services and a minimum of one year of qualifying experience including care management or casework with persons who have HIV infection, a history of mental illness, homelessness or chemical dependence; OR an Associate degree in health or human services and two years of qualifying experience or certification as an R.N. or L.P.N. and two years of qualifying experience. Computer proficiency is required. Fluency in Spanish and/or ASL preferred. Must be accustomed to diversity.

Physical Requirements

While performing the duties of this job the employee is required to stand, sit, walk, use hands to finger, handle, or feel; reach with hands and arms, talk and hear. Occasionally the employee must stoop, bend and lift or move up to 25 lbs. Specific vision abilities required include close vision, distance vision, peripheral vision, depth perception and ability to adjust focus.

In support of the Americans with Disabilities Act, this job description lists only those responsibilities and qualifications deemed essential to the position.

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