COMMUNITY HEALTH FELLOW - BILINGUAL

MISSION

The mission of Ravenswood Family Health Network (RFHN) is to improve the health of the community by providing culturally sensitive, integrated primary and preventative health care to all, regardless of ability to pay or immigration status, and collaborating with community partners to address the social determinants of health.

POSITION Summary


The Community Health Fellow, as a member of RFHN's School Integration Team (SIT), supports a clinic-school partnership model that extends RFHN medical home services into early childhood centers and elementary schools in East Palo Alto and Belle Haven. Anchored at RFHN's East Palo Alto location and embedded at partner school sites on a rotating schedule, the Fellow serves as a liaison between schools, families, and RFHN to help reduce barriers to care and address preventable health barriers to learning.

Reporting to the School Integration Team Lead, the Fellow provides direct outreach, navigation, and follow-up support to students and families; assists with coordination of preventive screenings and integrated services; and helps connect families to clinical and community resources. The Fellow also supports bidirectional communication between schools and medical homes, contributes to documentation and tracking of program activities and outcomes (including attendance-linked health supports), and participates in quality improvement efforts over the four-year grant period.

Duties and Responsibilities

To be performed in accordance with RFHN Policies and Procedures

Family/Patient Care Coordination (40%)

1. Take ownership for a panel of students/patients in need of care coordination, including cultivating relationships with students/patients and their families and increasing engagement from these families in their own health care management.
2. Implement a standardized approach to tracking and completing care needs for students/patients.
3. Conduct routine and ad hoc coordination visits with family including at home, at school locations, and virtually (phone and video).
4. Interact via text messaging, email, or other communication interfaces with families.
5. Provide longitudinal support in educating families on routine care needs relevant to school (i.e. hearing/vision screens, TB testing, lead testing) and assist in scheduling and conducting interventions.
6. Provide families with needed medical updates or records upon request or when required by the school district or other organizations.
7. Connect families to additional resources or community-based partners (i.e. CHC, WIC/CalFresh) and assist with any registrations, enrollment processes, or needed medical evaluations relevant to outside services.

School Coordination (40%):

1. Establish a presence at assigned school locations through relationship development and ongoing care coordination; create and maintain a predictable schedule for in-person visits (or "office hours) at school locations.
2. Comply with and complete any necessary onboarding or credentialing necessary to gain in-person access to school district locations.
3. Facilitate bidirectional information sharing between school locations and RFHN using approved release of information processes and information technology systems.
4. Learn about and share required school district components related to student health needs both with RFHN pediatrics teams as well as families of students to reduce barriers (i.e. med administration forms, asthma action plan completions, seizure rescue plans, food allergy emergency plans).
5. Communicate important education-related changes (i.e. IEP planning meetings, counselor assignment or removal) to medical home.
6. Educate school staff on routine pediatric primary care approaches to care and work to improve the integration of educational and clinical workflows to reduce barriers to families and areas of friction for school districts.

Project Development (20%):

1. Attend and participate in regular School Integration Team meetings and educational opportunities.
2. Attend and participate in larger RFHN Pediatrics Department meetings, seminars, and trainings relevant to the SIT.
3. Work with the School Integration Team lead as necessary to further grant goals including policy or procedure development, release of information creation (including potential user testing, training, implementation).
4. Collect, analyze, and provide required data either for grant reporting or for internal quality improvement efforts.
5. Perform other duties as assigned to support the mission and operations of RFHN.

QUALIFICATIONS

• High School Diploma or equivalent (GED) required.
• Experience in clinical environments or prior clinical training a plus but not required.
• Experience in health promotion and behavior change, wellness, or health education preferred.
• Familiarity with primary educational environments and systems preferred (i.e. preschool, elementary, middle school).
• Computer skills, including Microsoft Excel, Word, and PowerPoint.
• Proficiency with electronic health records, Epic a plus.
• Bilingual Spanish/English proficiency required.
• Must be able to travel between clinical locations and school sites as required.
• Up to date with COVID-19 vaccines per current CDC guidelines strongly recommended.

Ravenswood Family Health Network is an equal opportunity employer.