Health Care Navigator - Supportive Services for Veteran Families (SSVF)

The Salvation Army Mission:

The Salvation Army, an international movement, is an evangelical part of the universal Christian church. Its message is based on the Bible. Its ministry is motivated by the love of God. Its mission is to preach the gospel of Jesus Christ and to meet human needs in His name without discrimination.

Job Objective: Provide services connecting SSVF eligible Veterans who are homeless or at risk of homelessness to VA health care benefits, or community health care when Veterans are ineligible for VA care. Provide case management, care coordination, health education, interdisciplinary collaboration, consultation, quality improvement, and risk management working with the Veteran's primary care provider and the assigned interdisciplinary treatment team.

Essential Functions:

Non-Clinical Assessment

• Conduct assessments in collaboration with the interdisciplinary treatment team, the Veteran, family members, and significant others to assess the Veteran's situation, potential barriers to care, causes, and impact of barriers on the Veteran's ability to access and maintain health care services

Health Care Team and Veteran Communication

• Work closely with Veterans and assist in communicating Veteran care preferences and personal health goals to facilitate shared decision making of the Veteran's care
• Serve as a resource for education and support for Veterans and families and identify appropriate Veteran-centered supports

Community Services, Outreach, and Referrals to Support Veteran's Care Plan

• Participate in the development of the Veteran's care plan with an emphasis on community services, outreach, and referrals needed for the Veteran
• Develop the plan in collaboration with the interdisciplinary treatment team, Veteran, family members, and significant others; incorporating measurable goals
• Regularly review care plan goals with the Veteran, conduct ongoing non-clinical barrier assessments, and provide resources and referrals needed to support adherence
• Evaluate effectiveness of resources and referrals provided and make modifications to ensure provision of high-quality care and interventions
• Monitor and document progress and provide updates to the treatment team as appropriate

Specialized Case Management and Care Coordination

• Provide comprehensive case management and care coordination across episodes of care acting as a health coach by proactively supporting the Veteran to optimize treatment interventions and outcomes
• Modify services to meet the Veteran's needs and coordinate services with other organizations/programs to assure provision of complementary and comprehensive services. Represent the program in contacts with other agencies and the public
• Coordinate additional supportive services to ensure Veteran and caregivers are linked to supportive services, including but not limited to, housing, financial benefits, and transportation
• Coordinate referrals to VA, community health clinics, and other programs needed to ensure access to health care
• Follow the care plan to facilitate adherence, and collaborate with community providers to maximize use of VA and community resources
• Act as an advocate for the client, integrating the Veteran's cultural values into the care plan
• Assist Veteran to identify methods to monitor progress toward meeting health goals. Provide ongoing follow up

Health Education

• Educate Veterans and caregivers on available services and assist with referrals based on Veterans preferences
• Assist in identifying the Veteran and family's health education needs and provide education services and materials that match the health literacy level of the Veteran
• Provide ongoing education support as needed based on identified needs

Interdisciplinary Collaboration, Coordination and Consultation

• To promote the highest level of quality car, collaborate with the health care provider, interdisciplinary care team, and the SSVF team, regularly consulting on ongoing assessment of Veteran needs
• Act within professional boundaries and roles appropriately, respecting the roles of others involved in care and services

Risk Management & Infection Control

• Complete required training including: Safe from Harm, Blood Borne Pathogens, The Salvation Army's Case Work Certification Program, Confidentiality, Ethics, Suicide Prevention, and all SSVF Health Care Navigator training
• Report any accidents or injuries to self or clients and complete appropriate documentation
• Follow risk management plan, infection control practices (i.e., hand washing, universal precautions/isolation procedures, and precautions), follow protocols specific to COVID-19 prevention, and all safety protocols vital to staff and Veteran safety

Confidentiality, Computer Security, and Ethical Practice

• Adhere to ethical standards of practice and principles of confidentiality, informed consent, compliance with relevant laws, and agency policies (e.g., critical incident reporting, HIPPA, Duty to Warn)
• Ensure client confidentiality is maintained in accordance with established procedures and regulations

Continuous Quality Improvement (CQI) and Systems Improvement

• Participate in expanding knowledge related to health care navigation with the Veteran population
• Assist in identification of systemic and organizational barriers and work collaboratively with the organizational leadership to find viable solutions
• Assist in development of policy, procedures, and practice guidelines related to Health Care Navigation, using knowledge gained from research on best practices
• Develop relationships with community contacts, VA staff, and other referral networks and provide subject matter expert consultation to staff and community providers as requested. Assist in development of internal evaluation components, outcomes indicators, and potential reporting of evaluation results to VA and organizational leadership in collaboration with the Program Director
• Participate in case reviews and progress updates in team meetings
• Submit monthly reports as required on activities and unmet needs
• Attend in-service and outside trainings as requested. Assure service delivery in compliance with VA-SSVF program regulations, SSVF Program Guide, SSVF policies/procedures, The Salvation Army's policies/procedures, 38 CFR Part 62, and policies/procedures/waivers specific to COVID-19 as instructed by the VA-SSVF Program Office

Customer Service

• Participate effectively in team meetings, case conferences, and related activities
• Collaborate with multidisciplinary team members to enhance coordination of comprehensive Veteran care
• Effectively communicate and utilize community agencies to facilitate continuity of care

Age, Development, and Cultural Needs of Veteran Clients

• Consistent sensitivity to all Veteran's needs concerning age, developmental requirements and culturally related factors and consideration of age-related differences in the provision of care

Minimum Qualifications:

Education: Master of Social Work required; relevant experience, as determined by The Salvation Army, may be considered in lieu of education.

Experience: Prior experience performing medically based social work case management in collaboration with a medical and interdisciplinary team preferred. Experience serving homeless population and Veterans preferred. Prefer experience with crisis intervention, community resources, and use of technology and databases for entering case data and case notes.

Certifications/Licenses: LMSW/LCSW preferred but not required

Skills/Abilities:

• Advanced social work skills
• Ability to function independently while seeking supervisory consultation
• Ability to exercise sound judgment and initiative in day to day activities based on expertise accumulated through education, training, experience, and staying abreast of best practice literature
• Ability to use computer technology for documentation, date entry, and virtual platforms
• Excellent customer service, interpersonal and collaborative skills
• Ability to concentrate on work for sustained periods of time
• Ability to employ critical thinking, and creative problem-solving skills
• Ability to adapt to culturally diverse environments, exhibit respect for cultural differences and be comfortable working with vulnerable populations
• Ability to operate office equipment including telephone, personal computer, copier, fax, and scanning equipment
• Ability to speak, write, and understand English for effective professional level communication

Supervisory Responsibility: None

Physical Requirements: Include sitting, walking, standing, bending, squatting, climbing, kneeling, and twisting; grasping, pushing, pulling and lifting objects up to 25 lbs.; reaching overhead. Reasonable accommodation may be made to enable individuals to perform the essential functions of this job.

Travel: Ability to travel 25-50% of the time with most travel being local and limited overnight travel.

Driving: Must possess a valid driver's license in the state of residence. Must be approved through The Salvation Army Fleet Safety Program to drive either a Salvation Army or personal vehicle on Salvation Army business. For use of a personal vehicle appropriate insurance must be maintained.

Working Conditions: Work conditions are varied with some work performed in the office and some in the community. Work is other than routine with frequent interruptions and changing priorities. Deadlines are a regular part of the job. Under direction where definite objectives are established, must plan and arrange a significant portion of own work, referring only unusual cases to supervisor or others, and possess the ability to prioritize work. Will often engage with others in the community to form collaborative alliances.

All employees recognize that The Salvation Army is a church and agree that they will do nothing as an employee of The Salvation Army to undermine its religious mission.