Linkage to Care Specialist

Linkage To Care Specialist

Reporting to the Linkage to Care Specialist Supervisor, the Linkage to Care Specialist is responsible for identifying HIV-positive individuals as well as persons at greater risk of acquiring HIV and facilitating linkage/re-engagement into medical and supportive services as appropriate. Specifically, the Linkage to Care Specialist is responsible for:

• Providing HIV and Hepatitis C counseling, testing, and referral services and HIV prevention health education to individuals in the community;
• Identifying individuals who are not engaged in medical care and assisting them in getting linked/re-engaged into services;
• Assessing and documenting eligibility for Ryan White services, and referring individuals who are un-/under-insured immediately to insurance/entitlement programs;
• Developing strategies to remove patients' identified barriers to care;
• Using proven behavioral strategies to enhance motivation and willingness to participate in medical care and supportive services; and
• Monitoring the patient and providing support and referrals as appropriate up to and including the second kept HIV medical appointment.

Linkage to Care Specialists are assigned to a variety of venues that include medical centers, substance abuse programs, hospitals, correctional facilities, shelters, transitional housing, churches, LGBT community events, etc.

Contacts and interactions vary and may involve multiple constituencies such as direct interaction with THC's executive management, community organizers, the general public, THC's patients, physicians, colleagues, assigned staff, vendors, contractors and consultants for the purpose of providing and exchanging information.

Example of Essential Job Functions

• Establishes relationships with providers and key personnel throughout the system of care, as well as with outside agencies in order to provide rapid testing.
• Provides on-site Rapid HIV and Hepatitis C testing in the community and at Total Health Care sites, as needed.
• Refers any positive results to the Maryland Department of Health as required by law.
• Provides Pre/Post-test counseling for any HIV positive and Hepatitis C positive individual. Completes necessary documentation of test results and services provided as required by funders and applicable laws.
• Performs a comprehensive assessment to all HIV-positive clients identified/referred to identify medical and psychosocial needs; barriers to care; understanding of HIV disease; and understanding and knowledge of available Ryan White services and resources.
• Develops and implements an individual intervention plan to all HIV-positive clients identified/referred that addresses needs and barriers identified in the comprehensive assessment. Identifies linkage to appropriate services and resources, whether internal or external.
• Provides referrals to medical and psychosocial support services to any individual encountered in the community during a community event, including persons who are HIV-positive or HIV-negative.
• Demonstrates competency in the delivery of behavioral change models (e.g. Harm Reduction, Motivational Interviewing, Stages of Change, etc.).
• Demonstrates competency in speaking with individuals regarding HIV prevention strategies, including PrEP/nPEP, U=U, Treatment as Prevention, etc.
• Communicates with patients by phone, mail, and community and home visits as needed.
• Works as part of the multi-disciplinary team to provide tools and strategies using a patient-centered approach to support individuals being tested and linked to care. Attends weekly multi-disciplinary care team meetings.
• Attends and actively participates in all required staff meetings, trainings, conferences, and supervision.
• Participates in the coordination and implementation of special events such as health fairs, HIV testing day events, holiday campaigns, corporate sponsorships and other outreach activities.
• Coordinates and facilitates educational groups at various venues.
• Prepares and processes forms, spreadsheets, and reports to appropriately document activities and services rendered. Collects and forwards feedback on program services and community activities to the Linkage to Care Supervisor.
• Demonstrates awareness of program and grant goals, including their role in helping the program to meet its deliverables.
• Establishes and maintain relationships with Total Health Care providers and staff, as well as community agencies in order to connect patients to services.
• Gathers patient data and clinical information to enter data into the Practice Management System, Electronic Medical Record and CAREware reporting system.
• Schedules medical and other appointments on behalf of patients as needed.
• Gathers and documents attempts to gather program eligibility information.
• Demonstrates flexibility and is able to work in a changing environment with a positive perspective.
• Adheres to all Total Health Care Human Resources Policy & Procedures, including but not limited to maintaining a positive attitude, appropriate dress, timeliness and attendance, and maintaining professionalism toward other Total Health Care staff, patients, community partners, and individuals in the community.
• Ensures personal social media does not conflict with one's ability to maintain respect in the Total Health Care community.
• Travel is required.
• Other duties as assigned.

Minimum Education, Training and Experience Required

• High School Diploma required
• Rapid HIV certification preferred.
• Rapid Hepatitis C training preferred
• Certified Phlebotomy preferred
• Experience in working in the HIV community in Baltimore is preferred

Required Knowledge, Skills and Abilities Knowledge of HIV disease, including prevention strategies, treatment options, and available services in the community. Ability to present information to large groups of individuals during community events. Ability to develop and maintain relationships, and build credibility and trust in the community. Excellent customer service, communication, and interpersonal skills. Ability to multi-task and prioritize as appropriate. Ability to plan and organize work load to meet personal, team, and department goals.

Licenses and Certifications

• Certification in Rapid HIV Counseling and Testing in Maryland
• Phlebotomy Certification preferred