Linkage to Care Specialist

J ob Summary

Reporting

to the Linkage to Care Specialist Supervisor, the Linkage to Care Specialist is

responsible for identifying HIV-positive individuals as well as persons at

greater risk of acquiring HIV and facilitating linkage/re-engagement into

medical and supportive services as appropriate. Specifically, the Linkage to

Care Specialist is responsible for: 1) Providing HIV and Hepatitis C counseling,

testing,& referral services and HIV

prevention health education to individuals in the community; 2) Identifying

individuals who are not engaged in medical care and assisting them in getting

linked/re-engaged into services; 3) Assessing and documenting eligibility for

Ryan White services, and referring individuals who are un-/under-insured

immediately to insurance/entitlement programs; 4) Developing strategies to

remove patients’ identified barriers to care; 5) Using proven behavioral

strategies to enhance motivation and willingness to participate in medical care

and supportive services; and 6) Monitoring the patient and providing support

and referrals as appropriate up to and including the second kept HIV medical

appointment.

Linkage

to Care Specialists are assigned to a variety of venues that include medical

centers, substance abuse programs, hospitals, correctional facilities,

shelters, transitional housing, churches, LGBT community events, etc.

Contacts and interactions vary and may involve multiple

constituencies such as direct interaction with THC’s executive management,

community organizers, the general public, THC’s patients, physicians,

colleagues, assigned staff, vendors, contractors and consultants for the

purpose of providing and exchanging information.

Example of Essential

Job Functions

• Establishes relationships with providers and key personnel throughout
  
  

the system of care, as well as with outside agencies in order to provide rapid

testing.

• Provides on-site Rapid HIV and Hepatitis C testing in the community and
  
  

at Total Health Care sites, as needed.

• Refers any positive
  
  

results to the Maryland Department of Health as required by law.

• Provides
  
  

Pre/Post-test counseling for any HIV positive and Hepatitis C positive individual.

Completes necessary documentation of test results and services provided as

required by funders and applicable laws.

• Performs a comprehensive
  
  

assessment to all HIV-positive clients identified/referred to identify medical

and psychosocial needs; barriers to care; understanding of HIV disease; and

understanding and knowledge of available Ryan White services and resources.

• Develops and
  
  

implements an individual intervention plan to all HIV-positive clients

identified/referred that addresses needs and barriers identified in the

comprehensive assessment. Identifies linkage to appropriate services and

resources, whether internal or external.

• Provides referrals to
  
  

medical and psychosocial support services to any individual encountered in the

community during a community event, including persons who are HIV-positive or

HIV-negative.

• Demonstrates
  
  

competency in the delivery of behavioral change models (e.g. Harm Reduction,

Motivational Interviewing, Stages of Change, etc.).

• Demonstrates
  
  

competency in speaking with individuals regarding HIV prevention strategies,

including PrEP/nPEP, U=U, Treatment as Prevention, etc.

• Communicates with
  
  

patients by phone, mail, and community and home visits as needed.

• Works as part of the multi-disciplinary team to provide tools and
  
  

strategies using a patient-centered approach to support individuals being

tested and linked to care. Attends weekly multi-disciplinary care team

meetings.

• Attends and actively participates
  
  

in all required staff meetings, trainings, conferences, and supervision.

• Participates in the
  
  

coordination and implementation of special events such as health fairs, HIV testing

day events, holiday campaigns, corporate sponsorships and other outreach

activities.

• Coordinates and
  
  

facilitates educational groups at various venues.

• Prepares and processes forms, spreadsheets, and reports to
  
  

appropriately document activities and services rendered. Collects and forwards

feedback on program services and community activities to the Linkage to Care Supervisor.

• Demonstrates
  
  

awareness of program and grant goals, including their role in helping the

program to meet its deliverables.

• Establishes and
  
  

maintain relationships with Total Health Care providers and staff, as well as

community agencies in order to connect patients to services.

• Gathers patient data
  
  

and clinical information to enter data into the Practice Management System, Electronic

Medical Record and CAREware reporting system.

• Schedules medical and other appointments on behalf of patients as
  
  

needed.

• Gathers and documents attempts to gather program eligibility
  
  

information.

• Demonstrates flexibility and is able to work in a changing
  
  

environment with a positive perspective.

• Adheres to all Total
  
  

Health Care Human Resources Policy & Procedures, including but not limited

to maintaining a positive attitude, appropriate dress, timeliness and

attendance, and maintaining professionalism toward other Total Health Care

staff, patients, community partners, and individuals in the community.

• Ensures personal
  
  

social media does not conflict with one’s ability to maintain respect in the

Total Health Care community.

• Travel is required.
• Other duties as
  
  

assigned.

Minimum Education,

Training And Experience Required

• High
  
  

School Diploma required

• Rapid
  
  

HIV certification preferred.

• Rapid
  
  

Hepatitis C training preferred

• Certified
  
  

Phlebotomy preferred

• Experience
  
  

in working in the HIV community in Baltimore is preferred

Required Knowledge,

Skills And Abilities

Knowledge

of HIV disease, including prevention strategies, treatment options, and

available services in the community. Ability to present information to large

groups of individuals during community events. Ability to develop and maintain relationships,

and build credibility and trust in the community. Excellent customer service,

communication, and interpersonal skills. Ability to multi-task and prioritize

as appropriate. Ability to plan and organize work load to meet personal, team,

and department goals.

Licenses and Certifications

Certification in Rapid HIV Counseling and

Testing in Maryland

Phlebotomy Certification preferred