Description

 Contessa offers a unique opportunity for individuals interested in being part of an organization that is leading the country in redefining the way care is provided to patients. Contessa’s care delivery models bring all the essential elements of inpatient and outpatient care to the comfort and convenience of a patient’s home. Our models enable provider organizations and health plans to deliver high-quality, safe and affordable care to patients with a broad range of health conditions. At Contessa, you will have the opportunity to make a direct impact on the lives of patients and be at the forefront of shaping a pioneering space in the health care industry.

About the Chronic Care Management (CCM) and Palliative Care at Home Program:

The CCM and Palliative Care at Home Program is a community-based program for adults with serious illness and their caregivers offered by a unique company, Contessa Health, owned by Amedisys. The program provides coordinated, high quality, interdisciplinary care to patients and families facing challenges associated with advanced illnesses.

The full clinical team is comprised of community health workers, nurse practitioners, nurses, social workers, and physicians. The clinical team will work in collaboration with patients’ other healthcare providers to provide high quality, evidence-based complex, chronic care management, and palliative care in patients’ homes, supported by robust guidelines and care processes. Contessa and Amedisys’ other home-based services, such as Hospital at Home, Home Health and Hospice, all work to support patients and caregivers in their homes.

The program is designed to improve symptoms and quality of life, reduce caregiver burden, and reduce unnecessary hospitalizations and ED visits.

Primary Responsibilities:

We are seeking to recruit a dynamic and enthusiastic full-time community health worker to work within the CCM and Palliative team. The responsibilities will include:

• Serving as a link between health and social care services and the community to improve access to services and improve the quality of care delivery
• Developing an understanding of the patient and caregivers’ illness understanding and health literacy
• Following up on goals of care discussions, and ensuring all care plans consider the importance of culture and literacy
• Monitoring patient and caregiver needs, including both symptom needs and home needs
• Working closely with the interdisciplinary team to address changes in patient symptoms and care needs
• Coordinating patient care, including helping with scheduling appointments and providing reminders and follow-up after appointments/hospitalizations
• Providing education on the importance of treatment adherence and use of medications
• Connecting patients with community-based resources and assisting with screening/enrollment procedures for such resources
• Providing psychosocial support, which may include informal supportive counseling and motivational coaching
• Promoting personal empowerment and patient/caregiver engagement in health, including navigation of the healthcare system
• Promoting literacy around health and social care problems and their management
• Educating patients and caregivers about the course of illness and helping them understand the disease trajectory and expected outcomes
• Participating in the weekly IDT meeting, together with the rest of the care team

Requirements

• High school education, GED, or equivalent
• Certified Home Health Care Worker, or Home Health Aide (depending on local laws and regulations)
• Health Coaching Certification
• At least 2 years of experience working with patients in a home-care environment
• Excellent communication skills and ability to connect with patients and caregivers
• Competence in utilizing multiple software applications on computer and mobile devices
• Compassionate with a strong desire to improve care for seriously ill individuals and their families
• Experience and comfort working in home settings with patients and families, including those in difficult living conditions/environments
• Traits that include professionalism, a passion for palliative care, open and non-judgmental style, personal warmth, tact and patience with both professionals and patients and caregivers
• Experience working in interdisciplinary teams
• Working knowledge of medical terminology and the healthcare system
• Ability to ask both open-ended and specific questions during telephonic encounters with patients, and communicate concerns with clinical team members in an effective and timely manner
• A positive commitment to being part of a home-based palliative care program
• Ability to embrace a concurrent and long-term palliative care philosophy and practice, particularly if already trained in the philosophy and practice of hospice or home health care
• Comfort discussing patients’ values, priorities, and preferences for care and representing these to the rest of the team
• Ability to act as an effective advocate for patients and caregivers
• Ability to work in highly emotionally charged situations with patients and families, while also monitoring their own reaction to patients with serious illness and their families

• Desirable Skills / Experience
• Palliative care/hospice experience
• Advanced communication skills
• Fluent in Spanish

• Physical Ability
  • Ability to travel to and from patient’s homes on public or private transportation
  • Ability to climb several flights of stairs
  • Ability to lift/carry 10-15 lbs