Integration Specialist (BA)

Integration Specialist

The Integration Specialist provides Health Home services and similar supports for patients whose complex medical, behavioral health and social concerns impede their ability for self-care. The Integration Specialist is a member of the patient-centered inter-disciplinary Care Management team, and has a strong understanding of chronic conditions and how each condition can compound another, leading to poor health outcomes. The Integration Specialist meets with patients in the location of their choice; their homes, in the community, at in-patient settings or in clinics. This individual's work will include timely and effective screenings and appropriate referrals to internal Sea Mar service providers, community-based resources, and emergency services when indicated. Screenings may pertain to functional abilities, daily medical self-management skills, fall risk, depression, anxiety, drug and alcohol use, and other screenings when indicated. Through the use of motivational interviewing and other techniques, the Integration Specialist will work with the patient to create a Health Action Plan which includes long and short term goals with actionable steps that will help the client self-manage their chronic health conditions. As part of ongoing services, the Integration Specialist will follow up with the patient regularly to evaluate progress made towards completing their Health Action Plan goals. As part of the Care Management/ Health Home six core services, the Integration Specialist provides care transition assistance from in-patient settings, follow-up in the home, as well as community based care coordination, health promotion, patient and family support, referral to community and social support services, and comprehensive care management. As part of the clients' interdisciplinary team, the Integration Specialist will provide information and recommendations regarding the client's care.

Sea Mar Community Health Centers