Street Medicine Palliative Health Patient Navigator

About the Organization: SFDPH Whole-Person Integrated Care serves to provide care to people experiencing homeless by 1) connecting to transitional primary care 2) re-/connecting to social services 3) supporting client’s towards becoming “housing ready” for their transition from shelter health to their next destination, ideally their own permanent, supportive housing with established primary medical care.  

Shelter Health is one of 8 social medicine programs under the Whole Person Integrate Care umbrella. This position would be a vital part of care coordination, stabilization, and wrap-around services for adults experiencing homelessness.

About the Position: The Street Medicine and Palliative Health Patient Navigator will work with people experiencing homelessness or newly/marginally housed people who have serious and terminal medical diagnoses. The member will join the Primary Care team in weekly outreach to the Palliative Care cohort to develop skills and education about Palliative Care with people experiencing homelessness in San Francisco and to discuss complex cases. The NHC Member will also support the management of the referrals and outreach data to keep up-to-date records on the needs and gaps in the care of populations. Additionally, the NHC Member will participate in weekly huddles to connect during the week and make collective decisions on who needs outreach and follow-up.

Duties and responsibilities may include:

• Tracking patients to confirm program enrollment and engagement
• Providing follow-up and case management to deliver assistance and information
• Implementing patient engagement strategies to improve outcomes
• Educating patients on medical interventions and prevention
• Providing social service navigation
• Tracking, enrolling, and surveying patients for improvement
• Attending meetings and patient huddles
• Assisting in care coordination and resource referrals
• Tracking referrals and closing the referral loop
• Linking patients to care by scheduling appointments
• In the space below, list other major duties

Other major duties include:

• Updating and maintaining client databases (EPIC, Excel) for program evaluation
• Support with data visualization of client-served in WPIC programs (ex. Palliative Care)
• Attending and participating in relevant meetings
• In person outreach with multidisciplinary team
• Opportunities to present with team at conferences, trainings, and talks.

• Flexible
• Able to build strong relationships
• Community engagement/outreach skills
• Able to communicate effectively with individuals of diverse backgrounds and identities
• Compassionate
• Note from Host Site: We have found that people who are able to process emotional content around living and dying are better fits for this project.  We provide a lot of additional support to nurture people who are drawn to this unique population that tends to teach us as much as we teach them.

• Knowledge of AmeriCorps/Health Corps member requirements
• Skill with Microsoft Office or other software for a variety of data processing operations involving a range of problem solving, record keeping, correspondence, and service tracking options.

• Member uses initiative in carrying out recurring assignments following set procedures, independently
• The supervisor assigns service activities, advises on changes in procedures, and is available for assistance when required
• The supervisor assigns service activities in terms of project objectives and basic priorities and is available for consultation in resolving controversial issues.
• Note from Host Site: Site supervision is taken seriously and we are always available as needed for support.

• The service activities are reviewed for accuracy through spot checks, through complaints from customers, and through observation of the member at service.
• Completed projects are reviewed very generally to determine that objectives have been met and are in compliance with policies and regulations.

• Written and oral guides provide specific instructions for doing service
• Note from Host Site: Member will work closely with Palliative Care core group, including social worker and medical provider

• Member has to develop, analyze, or evaluate information before the service position can progress
• The facts or conditions of the service position are clear cut, predictable, and apply directly to the assignment
• The service position assignments vary significantly or often involve unusual circumstances and incomplete or conflicting data
• Note from Host Site: Client care varies from client to client, depending on the need. The member is expected to be in service collaboratively with the Palliative Care team to ensure continued care coordination and service navigation.

The NHC Member will:

• Serve Monday - Friday, 8:00AM - 5:00PM
• Serve approximately 36-40 hours per week at the host Site
• Serve primarily in-person
• Travel for a significant amount of time (more than 25%)
  • The NHC Member will outreach with the team to hospital(s), streets, and patients' residences for follow-up care coordination and direct patient support.

• No language other than English is required.

• No other Criminal History Check Requirements beyond NHC Standard Checks.