About Concerto Health
Concerto Health is an Irvine, CA-based company with one vision: to transform primary health care delivery for millions of people with complex health needs. The Concerto name reflects our unique approach to healthcare. It’s about how we work in concert with all aspects of the health care delivery system. Whether you’re a patient, provider, or health plan, the Concerto Health Primary Care Support Platform can help.
The Concerto Health care model changes everything – payment, staffing, processes, IT systems, and culture. Our model surrounds patients, families, caregivers, and provider groups with a multi-disciplinary team of health professionals and systems of care. Our innovative team-based approach to care delivers unparalleled results in the areas of team and patient experience, transitions of care, quality, and cost reduction, while simultaneously fostering a culture that humanizes health care delivery for those most in need.
We currently operate in 2 markets (Michigan and Washington) that include 3 primary care practices and 3 field-based teams, in partnership with innovative health plans and provider groups that share our vision. We will soon be operating in additional geographies.
The Health Coach I will serve as a key member of a multi-disciplinary care team, addressing the needs of our most medically and socially complex patients. Our care teams work in concert to bring close attention to the social determinants of health and an intense focus on engaging members in care management and during transitions of care, always seeking to identify root causes for avoidable utilization of the health care system.
The Health Coach I leads efforts to locate and engage new and previously hard-to-engage patients. This is accomplished through researching to identify accurate contact information and employing field-based activities, including meeting patients in emergency rooms, hospitals, and various community settings. The Health Coach I works with a panel of patients to promote an understanding of health information, education, available benefits and resources, and the necessary follow-up to ensure patients meet their care plans goals, reduce utilization, and improve health outcomes. The Health Coach I meets patients “where they are at” and builds supportive relationships which will address their social needs and ensure improved engagement in their medical and behavioral health care. This individual is a patient advocate, employs basic motivational interviewing skills, and works to overcome language and cultural barriers to engage and effectively work with patients.
ESSENTIAL DUTIES AND RESPONSIBILITIES
Specific responsibilities will include, but are not limited to, the following:
Outreach & Engagement:
- Persistently forges trusting relationships and engages individuals not initially interested in health care services.
- Utilizes basic motivational interviewing skills to gain agreement from patients to participate in the onboarding and person-centered care planning process.
- Uses internal and external resources (such as claims, referrals, and pharmacy data) to identify effective modes of communication with unreachable or hard-to-reach patients.
- Outreaches by phone to patients and travels to engage them in their homes, shelters, adult living facilities, emergency rooms, hospitals, and other community settings.
- Provides education to new patients regarding Concerto Health, including the onboarding process and the role of primary care, and facilitates new patient appointment coordination.
- Meet and engage patients in the Emergency Room (ER) to address their non-emergent needs, ensure they have a PCP, and address barriers to accessing their PCP.
- Actively manages an assigned set of patients that are determined to need ongoing support to self-manage their health conditions and maintain adequate engagement with their care team.
- Participates in and supports the effective planning, development, execution, and evaluation of patient care plan in collaboration with the patient’s assigned care manager, primary care provider and the rest of the patient’s care team.
- Implements care plan interventions via phone calls, home visits, and visits to other settings where patients can be found.
- Coaches on problem solving, self-care and self-management in an effort to close care gaps and to teach health promotion and prevention activities.
- Address barriers that get in the way of adopting a healthy life style (e.g., stress, weight loss).
- Perform home safety assessments to address barriers that get in the way of patients remaining independent in their homes and other community residential settings.
- Utilizes basic motivational interviewing skills to promote healthier behaviors, including adherence to chronic disease care plans and regimens, smoking cessation, reduction in unhealthy drinking and drug use, and addressing social barriers.
- Delivers coaching aspects of collaborative care for mental health and substance use disorders, including patient education, behavioral activation, and ongoing follow-up.
- Assists with healthcare navigation, including coordination of patient appointments, transportation, social services and supports, and referrals.
- Maintains a current list of community agencies and resources appropriate for patient needs.
- Acts as a patient advocate and liaison between the patient and community resources and community service agencies (i.e. DSHS, Heath Care for Homeless, hospitals, support groups, etc.).
Team Based Care and Collaboration:
- Utilizes established workflows and collaborates with internal stakeholders such as care team members, ancillary care team members, administration and operations staff.
- Participates in collaborative team meetings and patient care planning.
- Utilizes patient electronic health record and population management tools to track and document patient encounters.
- Travels between Concerto office locations and to various community settings as required
- Performs other duties as assigned.
Training and Continuing Quality Improvement:
- Attends and actively participates in initial and ongoing training on motivational interviewing, collaborative care, and various clinical topics.
- Welcomes feedback on audiotaped sessions with patients and on various performance measures to maximize skills and effectiveness.
- Minimum Education: High School Diploma or equivalent, preference for degree or certification in health care or social service field.
- Experience working in outreach or in the community with people who have medical and behavioral health conditions, social and interpersonal complexities impacting their lives preferred.
- Experience working in a community-based, multi-cultural setting.
- Highly enthusiastic and confident communication style capable of motivating others, including use of active listening and paraphrasing.
- Ideal candidates will want to work as advocates for their patients. They will also embrace the concept of team-work and mutual support of their colleagues, fostering a joyful work culture.
- Ability to investigate leads for patient outreach and engagement opportunities.
- Knowledge of community resources, health and social service systems in the local community, and skill in establishing working relationships with community partners with appropriate support.
- Intermediate written and verbal communication skills, including ability to communicate effectively and with patients and family members who speak English as a second language.
- Basic computer literacy to comply with department needs and expectations (i.e., inputting information into electronic health records; basic use of excel spreadsheets).
- Ability to work a flexible schedule, including periodic outreach duties evenings, nights, and weekends.
- Ability and means to travel as needed in a timely manner within Concerto Health Market designated counties, to locations that may have limited access to public transportation; proof of liability and property damage insurance on vehicle used is required. DRIVER REQUIREMENTS: A Licensed for a minimum of 3 years; No violations and/or accidents within 3 years; No vehicle related suspensions/reinstatements; No DUI, reckless or felony Driving with 7 years.