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 employees serve as an extension of this mission and demonstrate their commitment to an excellent client experience by:

• Understanding and empathizing with client needs
• Surpassing client expectations
• Demonstrating a high level of integrity
• Exhibiting compassion and commitment
• Advocating for social justice
• Taking pride in individual work as well as that of the team
• Continually learning to stay current with industry standards, best practices and technology

As a Sea Mar employee, the individual in this position commits to adherence to these values to their utmost ability and endeavors to strengthen and embody this mission daily.

Core responsibilities include:

• Prior to HAP, reviews screenings and electronic record and when appropriate reaches out to other service providers with whom patient has had contact to consult how to best support patient goals and ensure non-duplicative efforts. Discusses with patient, family, caregivers, and providers (with consent) about treatment options and preferences; coordinates initiation of health action plan and on-going care coordination and care management.
• Conducts mandatory screenings and optional screenings when indicated by diagnoses or history to identify care needs.
• Creates a health action plan (HAP) with the patient which includes a long term goal, short-term goals, and small actionable steps to meet goals.
• Provides six core services in accordance with Health Home program requirements: health promotion, support to patient/family, care coordination, comprehensive transitional care, referral to social and community resources, care management.
• Monitors patient (in person or by phone) regularly for changes in severity of symptoms, changes in life circumstances compounding self-care abilities, and medication side effects and encourages patient to relay, or relays when needed, this information to the medical provider and/or specialists of other disciplines.
• Uses motivational interviewing and other techniques to help patients achieve HAP goals.
• Reviews health action plan and screenings with patient and/or family every four months.
• Actively engages patients and supporters to increase chronic condition self-management behaviors
• Demonstrates knowledge and skills necessary to provide care appropriate to the age and abilities of the patients served.
• Maintains active communication with members of patient's care team. Supports clients as requested during provider visits. Ensures all medical providers are aware of all staff working with the client.
• Participates in case review and/ or other multidisciplinary meetings with the client's care team. Collaborates with other Care Management team members (Care Management RNs, Master's level Integration Specialists, and Care Managers) to develop strategies for working with complex clients.
• Consults with behavioral health providers when working with patients with behavioral health diagnoses who are seeing behavioral health therapist.
• Coordinates with community providers and case managers on patient's behalf when a need is identified.
• Documents daily all telephone calls, visits, collateral contacts and encounters according to departmental and organizational policies and procedures; gathers and monitors outcome measurements.
• Maintains appointment reconciliation in scheduling database
• Other duties as assigned.

The Integration Specialist may carry a caseload of 60 patients as assigned by Care Manager. Provides up to two contacts per month for high-intensity patients (one face-to-face contact and one telephone contact with patient, providers, or caregivers) with a step down to telephone contact when the patient has demonstrated stability.

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• The ability to work effectively with all persons and groups with respect and an awareness of cultural differences.
• Must have good organizational and communication skills and demonstrate professionalism and appropriate boundaries in all interactions.
• The person in this position shall have no history or evidence of alcohol or other drug misuse for a period of three (3) years prior to the date of employment at the facility, and no misuse of alcohol or other drugs while employed at this facility.
• This individual cannot be a person who has been convicted of a felony within the last seven years or ever been convicted of assault, abuse, fraud, or crimes that have brought harm to another financially, emotionally, or physically.
• This person must have a valid driver license, proof of auto insurance and a vehicle safe for daily use. Prior to hire this person must submit a driver's abstract demonstrating that s/he is safe to drive as deemed by Sea Mar's Health and Safety/Compliance Officer. Within the course of employment, a current driver's abstract may be requested.

Position requirements include:

• Must be able to complete job responsibilities in various locations; client's home setting, community setting, or clinic.
• Ability to understand medical terminology pertaining to chronic conditions.
• Ability to work with an interdisciplinary care team including medical providers, nursing staff, care coordinators, behavioral health and support staff.
• Must be able to perform independently and at the same time perform effectively and professionally as an interdisciplinary team member.
• Must be able/willing to work with translators if not bilingual.
• Must have or obtain CPR certification within initial probationary period and will maintain CPR certification throughout employment.

Language skills include:

• Bilingual English/Spanish preferred.
• Ability to read and interpret documents such as safety rules, operating and maintenance instructions, and procedure manuals.
• Ability to write routine reports and correspondence.
• Ability to communicate effectively one-to-one with patients, families, and colleagues.

Computer skills include:

• Typing proficiency of at least 45 wpm.
• Demonstrable computer skills and an ability to learn computer applications from manuals and webinars with minimal supervision.
• Working knowledge of Microsoft Office.
• Ability to learn and proficiently use programs as may pertain to use of electronic health records.

Mathematical skills include:

• Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals.
• Ability to compute rate, ratio, and percent and to draw and interpret bar graphs.

Reasoning ability includes:

• Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists.
• Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form.

Education and/or experience includes:

• BSW or BA/BS in Human Services, Health Sciences or related field with experience either in social service case management, or care coordination. Will