Description
Spend your gap year with Amate House! Develop your leadership skills, gain professional skills, and start your career in social justice with our fellowship program! Amate House offers year-long opportunities to serve Chicago in a variety of social service agencies. Fellows live in intentional community with other fellows, receive housing, health insurance, a small stipend, mentorship, and learn about the 5 Tenets of AH: social justice, community, service, faith, and stewardship.
POSITION SUMMARY:
The Population Health Fellow will provide direct service under the Population Health and Quality departments. The coordinator will enroll and provide care coordination services to patients with Medicaid and uninsured patients residing in nearby zip codes. The fellow will work with patients to improve self-management of diabetes, hypertension and mild/moderate depression through assessment, enhanced self-awareness, education, self-monitoring and eliminating barriers to self-care by screening and addressing social determinants of health. In addition, the fellow will serve as a bridge between the patient, the medical system, and community-based organizations by building trusting relationships with community members served by the program.
ESSENTIAL FUNCTIONS
• Conduct proactive outreach to patients who live in one of the targeted zip codes who have a qualifying condition(s) of hypertension, diabetes, and/or depression and children with adverse childhood experience to promote the program and enroll them into the program.
• Collaborate with the clinic staff and care team to increase awareness of offered services and create effective methods for communication and collaboration such as warm hand offs and referrals.
• Accept referrals of enrolled individuals from community-based organizations.
• Monitor patients with hypertension for recent self-monitored blood pressure readings, collect readings and share with provider and care team.
• Monitor patients with diabetes for frequent A1c results and schedule lab visits when due.
• Conduct periodic rescreening using the health risk screening tool to determine progress in addressing social determinants of health and identify any new ones.
• Use a worklist to identify and re-engage patients who are not participating as expected in the disease management program.
• Address patient’s social determinants of health (SDOH) and barriers to care.
• Identify and engage with community-based organizations (CBOs) through the IRIS electronic registry.
• Provide education, coaching, and motivational interviewing to support the patient in the self-management of their chronic conditions, including but not limited to the use of glucometers and blood pressure monitors for self-monitoring.
• Utilize data and information from Managed Care partners to monitor gaps in care.
• Document all encounters, outreaches, and other notes in Athena and MHN Connect.
• Participate in case reviews with other care team members (nurses, behavioral health providers, PCPs, care managers of high-risk enrollees as appropriate) of enrollees who are not making progress toward self-management goals. Provide the care team with patient updates and ensure the care plan is consistently updated and integrated with disease management information.
• Other duties as assigned.
EDUCATION, EXPERIENCE AND SKILLS REGQUIRED
• Bachelor’s degree in related field recommended.
• 1-3 years of experience, preferred in social services. Background in a community health setting is highly preferred.
• Knowledge utilizing Microsoft Office Suite (PowerPoint, Word, Excel, and Outlook).
• Must be dependable and have ability to exercise good judgment.
• Possess the ability to deal tactfully with personnel, patients, and visitors.
• Knowledge of safety rules, regulations, and guidelines pertaining to the operation of the medical center.
• Ability to work on a full-time flexible schedule.
• Bilingual ability may or may not be required based on individual department needs.
• Excellent guest relations skills. Able to collaborate and interact with a diverse group of health care professionals.
Spend your gap year with Amate House! Develop your leadership skills, gain professional skills, and start your career in social justice with our fellowship program! Amate House offers year-long opportunities to serve Chicago in a variety of social service agencies. Fellows live in intentional community with other fellows, receive housing, health insurance, a small stipend, mentorship, and learn about the 5 Tenets of AH: social justice, community, service, faith, and stewardship.
POSITION SUMMARY:
The Population Health Fellow will provide direct service under the Population Health and Quality departments. The coordinator will enroll and provide care coordination services to patients with Medicaid and uninsured patients residing in nearby zip codes. The fellow will work with patients to improve self-management of diabetes, hypertension and mild/moderate depression through assessment, enhanced self-awareness, education, self-monitoring and eliminating barriers to self-care by screening and addressing social determinants of health. In addition, the fellow will serve as a bridge between the patient, the medical system, and community-based organizations by building trusting relationships with community members served by the program.
ESSENTIAL FUNCTIONS
• Conduct proactive outreach to patients who live in one of the targeted zip codes who have a qualifying condition(s) of hypertension, diabetes, and/or depression and children with adverse childhood experience to promote the program and enroll them into the program.
• Collaborate with the clinic staff and care team to increase awareness of offered services and create effective methods for communication and collaboration such as warm hand offs and referrals.
• Accept referrals of enrolled individuals from community-based organizations.
• Monitor patients with hypertension for recent self-monitored blood pressure readings, collect readings and share with provider and care team.
• Monitor patients with diabetes for frequent A1c results and schedule lab visits when due.
• Conduct periodic rescreening using the health risk screening tool to determine progress in addressing social determinants of health and identify any new ones.
• Use a worklist to identify and re-engage patients who are not participating as expected in the disease management program.
• Address patient’s social determinants of health (SDOH) and barriers to care.
• Identify and engage with community-based organizations (CBOs) through the IRIS electronic registry.
• Provide education, coaching, and motivational interviewing to support the patient in the self-management of their chronic conditions, including but not limited to the use of glucometers and blood pressure monitors for self-monitoring.
• Utilize data and information from Managed Care partners to monitor gaps in care.
• Document all encounters, outreaches, and other notes in Athena and MHN Connect.
• Participate in case reviews with other care team members (nurses, behavioral health providers, PCPs, care managers of high-risk enrollees as appropriate) of enrollees who are not making progress toward self-management goals. Provide the care team with patient updates and ensure the care plan is consistently updated and integrated with disease management information.
• Other duties as assigned.
EDUCATION, EXPERIENCE AND SKILLS REGQUIRED
• Bachelor’s degree in related field recommended.
• 1-3 years of experience, preferred in social services. Background in a community health setting is highly preferred.
• Knowledge utilizing Microsoft Office Suite (PowerPoint, Word, Excel, and Outlook).
• Must be dependable and have ability to exercise good judgment.
• Possess the ability to deal tactfully with personnel, patients, and visitors.
• Knowledge of safety rules, regulations, and guidelines pertaining to the operation of the medical center.
• Ability to work on a full-time flexible schedule.
• Bilingual ability may or may not be required based on individual department needs.
• Excellent guest relations skills. Able to collaborate and interact with a diverse group of health care professionals.
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Living Allowance
$200
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$200 monthly
Benefits
Education award upon successful completion of service, Health coverage, Housing, Stipend, Student loan forbearance, Training
Additional Benefits
Food Budget provided.
Transportation to and from service site covered.
Three retreats throughout service year.
Each fellow is provided with opportunity to be matched with a professional mentor, a spiritual companion, and counseling resources. There are three service days and trainings for all fellows each service year as well as mentoring if wanted.
Education Benefits
College Degree
Education Requirements
College Graduate
Desired Languages
English
Other Conditions
Prohibits paid work outside of the sponsoring agency at any time
Subject to criminal background check
Age Requirement
21 - 29