The Clinical Care Team will take referrals from primary care providers and will work with the primary care team to accomplish the following tasks:
  Social support navigation for social determinants of health (SDOH) such as food insecurity, housing insecurity, etc.

• Compile and maintain a resource list for SDOH resources including eligibility criteria, referral process, and contact information
• Collaborate with primary care nurse and providers
• Provide in-person or remote social needs screening/assessment with primary care patients referred by nurse or provider
• Coordinate or make aware of social services resources, i.e., housing, clothing, food, mental health services, etc.
• Collaborate with other social workers to identify patient and community resources
• Conduct case management activities
  • Work with hospitals for discharge planning, follow-up and education
  • Assist with obtaining patient records from hospitals
  • Assist in securing needed medical equipment through community partners
  • Conduct follow-up on care plans
  • Identify patients lost to follow-up or overdue for care and assist them in returning to care
• May assist with specialty referral navigation
  • Schedule, coordinate, and track non-BCS specialist and imaging referrals
  • Assist with obtaining patient records from specialists and imaging centers
  • Compile and maintain resource list for specialty referrals including eligibility criteria, referral process, cost and contact information
• Assist patients to locate and access low-cost prescription options such as patient assistance programs, discount retailers, etc.
  • May assist with patient assistance program applications and serve as a patient-provider liaison with the drug companies
  • Assist patient with applications for programs such as CoverRx and RxOutreach
• May help with other regional primary care-based initiatives with a social work component
• Documents in patient's record, updates consults, and tags provider and/or clinical staff as necessary
• Provide patient education or find appropriate education resources

  Expectations may include:

• ·          Complete onboarding and orientation
• ·          Participate in regional office and primary care clinical meetings as requested
• ·          Attend provider meetings as requested
• ·          Attend Health Councils and other community meetings to build relationships with social service agencies and promote health department services
• ·          Identify barriers to care or assistance experienced by our patients and seek ways to address them

  Tools and Equipment:
1.      Personal Computer
2.      Telephone
3.      Fax Machine
4.      Printer
5.      Scanner
6.      Copy Machine
7.      Calculator
8.      Personal Vehicle
Other office related equipment as required

TB_HC