Patient Care Advocate

Salary Range: $23.08 To $28.19 Annually

About the Role

Committed to the constant pursuit of excellence in improving the health status of the patient and decreasing hospital readmission rates, ensures the safe and effective transfers of patients across the care continuum, serving as the bridge between the professional staff in a care setting (e.g., hospital), the patient and/or family, and the community healthcare provider. Informs and guides both staff and patients to ensure an effective care transition from the hospital to the patient’s home; helps teach and train patient self-management skills as well as enhancing patient-healthcare provider communication; and provides support to ACTIVATE staff, hospital personnel, and community partners in the field. Provides assistance by phone or in-person to high-risk beneficiaries by identifying social determinants of health and connecting them to community services. This position does not have direct reports.

Responsibilities

• Enrollment (20%)
  • Runs and screens daily census reports for potential patient enrollments
  • Meets with patient/family at hospital bedside to introduce the program and gather enrollment data
  • Reinforces program enrollment and patient responsibilities with the patient and caregiver
  • Prioritizes referrals and activities according to intensity, need, and required follow-up to ensure outcomes are met
• Advocacy (45%)
  • Ensures professional boundaries are maintained with all aspects of patient interaction and care while delivering patient care advocacy, including:
    • Serves as a Patient Care Advocate to the patient, coaching the patient and caregivers in addressing social determinants of health
    • Provides information and navigation to the patient and/or family for an effective care transition, improved patient self-management skills, and enhanced patient-healthcare provider communication
    • Evaluates aspects of each patient’s condition, diagnoses, medications, and support systems to formulate an individualized plan for successful outcomes in:
      • Medication self-management
      • Use of a dynamic patient-centered record
      • Appropriate primary care and specialist follow-up
      • Knowledge of red flags
    • Serves as a liaison between primary care providers and community resources on behalf of patients to ensure patient-centered coordination of care
    • Works in the hospital and community, makes rounds in the hospital, makes home visits, and follows up via phone calls
    • Acts as a continuing resource for hospital personnel, patients, and/or caregivers
• Data Collection & Custodian of Records (20%)
  • Completes necessary assessments and referrals by collecting data on clinical indicators
  • Maintains databases on ACTIVATE-enrolled population, ensuring accurate and timely documentation
• Continuous Improvement & Quality (20%)
  • Ensures compliance with all AllThrive 365 policies, procedures, and practices regarding the Activate Transitional Care program, and other contract and licensure requirements, laws related to patient confidentiality, release of information, and HIPAA
  • Uses safe work practices and promptly reports workplace and patient safety issues to supervisor
  • Attends and actively participates in initial and ongoing training and development programs, weekly unit meetings, all staff meetings, and demonstrates learned concepts on the job
  • Participates in assigned work teams, as requested and appropriate
  • Engages in continuous improvement efforts and strives to continuously improve the quality of care and self
  • Communicates daily and as necessary with colleagues, supervisor, leadership, and medical staff
• Miscellaneous (5%)
  • Building, cleaning, and organizing durable medical equipment
  • Other duties as assigned

Requirements

• Education & Experience
  • Bachelor’s Degree in Social Work, Human Services, Psychology, or Public Health or Nurse (LPN or RN) Licensed by the Arizona Board of Nursing
  • Minimum of 2 years of working with patients in a primary care setting or related work experience
  • Valid AZ driver’s license and acceptable MVR
  • Valid CPR/First Aid Certification or ability to obtain within 30 days of position entry
  • Must be at least 21 years of age
  • Clear fingerprint background screening through the Department of Public Safety and comprehensive background clearance
• Skills
  • Excellent verbal, written, reading, and listening communication skills, including communicating clearly, effectively, tactfully, and patiently to a diverse population
  • Strong interpersonal skills and demeanor with the ability to build rapport and garner trust with others
  • Accurate keyboarding skills
  • Strong planning, organization, and time management skills to meet deadlines
  • Proficient in the use of healthcare data management systems such as CarePort, Cerner, and Apricot
  • Proficient in the use of a PC, Windows environment, Internet, MS Office Applications (Outlook, Teams, Word), and SharePoint
• Abilities
  • Ability to interact with others in a professional, respectful, positive, helpful manner, promoting trust and building and maintaining strong, effective working relationships with internal and external customers
  • Ability to follow-up and follow-through with strong attention to detail
  • Ability to follow oral and written instructions
  • Ability to maintain patient confidentiality, privacy, and dignity at all times
  • Ability to work both independently and collaboratively as part of a team
  • Ability to travel up to 50% of the time within the Greater Metropolitan Phoenix area using a personal vehicle properly insured
  • Ability to solve problems by applying analytical skills, including:
    • Collecting and reporting information
    • Identifying trends and exceptions
    • Investigating to define problems more accurately
    • Sorting information in order of importance
    • Identifying relationships and linkages between components
    • Identifying variable potential causes and effects
    • Soliciting guidance to define criteria and assign values of importance and urgency
    • Escalating issues of an exceptional nature
  • Willingness and ability to embody AllThrive 365’s core values: Compassion, Growth, Resilience, Openness

Physical Demands

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this position. The work environment characteristics described are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Normal office environment; clinical or patient care setting to include hospitals, physician offices, clinics, and patient homes.

• Regularly required to talk and hear, including over the telephone, in normal range
• Use hands to finger, handle or feel objects, tools/equipment, or controls
• Sit for extended periods of time, stand, reach with hands and arms, and walk
• Occasionally required to stoop, kneel, or crouch
• Lift and/or move up to 30 pounds
• Vision requirements include close vision, distance vision, and ability to adjust focus

Preferences

• Healthcare experience
• Knowledge of needs of older adults, the aging process, and the needs of adults with disabilities, adults with traumatic brain injuries (TBI), or serious mental illness (SMI)
• Bilingual in English/Spanish