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Project Description: LEAP (Liver Education & Action Program) at Mount Sinai aims to improve the treatment of hepatitis C (HCV) infection in NYC. It is estimated that 146,500 NYC adults (2.4% of the NYC population) have chronic HCV infection, which causes cirrhosis, end-stage liver disease, liver cancer, and death in 20% of infected persons. LEAP utilizes comprehensive care coordination to assist medical providers in improving overall outcomes related to treatment while reducing psychosocial and behavioral barriers to care.
The Care Coordinator will provide care coordination (case management, education, outreach, collaboration, and logistical support) to patients with chronic hepatitis C, including patients co-infected with HIV or who have diabetes. The care coordinator will be responsible for providing guidance and support to the HCV patient as they navigate the HCV treatment process. A successful care coordinator will build working relationships, solve problems, and connect patients with onsite and community resources.
- Develop effective relationships with patients and their caregivers as well as the medical team to promote interdisciplinary communication, continuity of care, and adherence to patients’ care plans
- Provide a central point of contact and escalate concerns appropriately
- Collect all HCV-related data and input in timely manner into program database; document encounters in electronic medical record
- Maintain all HCV-related databases (e.g. updating data daily, ensuring data security) that are required as part of the program
- Promote and monitor appointment adherence with appointment reminders and follow-up calls and letters
- Conduct brief alcohol, substance use, and mental health screenings and/or interventions
- Administer pre-treatment readiness assessments to identify potential barriers to treatment (e.g. using standardized instrument such as PREP-C and/or reaching out to patient’s primary care provider)
- Provide education on the natural history of HCV, prevention of transmission, evaluation, treatment, adherence, and side effect management, as well as general healthy living, alcohol, and substance use
- Provide patients with referrals to internal and community resources, including primary care providers, social services, mental health and substance use resources, and support group
- Check in with patients after appointment with liver provider for 5-10 minutes
- Assess how patient is doing (build rapport)
- Ask patient to clarify next steps
- Schedule follow-up appointments in real-time (e.g. ultrasound)
- Elicit fears and concerns
- Answer questions
- Work with any insurance issues and refer to on-site finance office or on-site social worker
- Work with pharmacies and providers to prepare prior authorizations for medications, order/deliver/dispense medications, and assess patient adherence to medications
- Provide adherence counseling and monitor patient-reported side-effects via weekly calls, and report to provider as needed
- Accept and coordinate in-house and outside HCV referrals from liver providers, primary care physicians, and the LEAP linkage to care team
- Outreach previously screened HCV-positive patients who have not been treated
- Schedule patients for all appointments including first on-site HCV evaluation with on-site HCV specialist, treatment meetings, and follow-up appointments on-site and off-site
- Accompany patients to on-site or off-site appointments when necessary
- Obtain outside medical records as needed
- Follow up on labs ordered by the HCV provider and review results to complete evaluation
- Prepare and co-lead, with other care coordinators, a monthly support group for HCV patients
- Organize and administer any program incentives (e.g. metro cards)
- Report to Program Manager
- Meet with Program Manager one-on-one
- Bi-weekly to case conference and go over any logistical concerns
- Monthly to review data and case load
- Attend team meetings and contribute to case presentations; participate in group case conferences, problem-solving, and process improvement discussions
- Attend on-site and off-site trainings as needed
- Potentially work with community partners to develop and maintain HCV-related networks (e.g. syringe exchange program and CBOs)
- Other duties as needed
- A Bachelor of Science in Public Health, Social Work, Biology, Psychology or an equivalent degree (minimum requirement); Master’s degree preferred
- Have at least 4 years of experience in a community health role
- Social work background preferred
- Must possess knowledge of community resources and health care processes, structures, and functions
- Preferred bilingual (English and Spanish)
- Must possess knowledge and experience with personal computers, especially Microsoft Office Suite (Excel, Outlook, Access, Word, PowerPoint) and electronic medical records
- Strong interpersonal skills
- Must demonstrate ability to work effectively in a team environment
- Must have excellent oral and written communication skills
- Demonstrate independent judgment
- Willingness to take on new tasks as needed
The Mount Sinai Health System believes that diversity is a driver for excellence. We share a common devotion to delivering exceptional patient care. Yet we’re as diverse as the city we call home- culturally, ethically, in outlook and lifestyle. When you join us, you become a part of Mount Sinai’s unrivaled record of achievement, education and advancement as we revolutionize medicine together.
We work hard to acquire and retain the best people, and to create a welcoming, nurturing work environment where you can develop professionally. We share the belief that all employees, regardless of job title or expertise, can make an impact on quality patient care.
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Over 38,000 employees strong, the mission of the Mount Sinai Health System is to provide compassionate patient care with seamless coordination and to advance medicine through unrivaled education, research, and outreach in the many diverse communities we serve.
Formed in September 2013, The Mount Sinai Health System combines the excellence of the Icahn School of Medicine at Mount Sinai with seven premier hospital campuses, including Mount Sinai Beth Israel, Mount Sinai Beth Israel Brooklyn, The Mount Sinai Hospital, Mount Sinai Queens, Mount Sinai West (formerly Mount Sinai Roosevelt), Mount Sinai St. Luke’s, and New York Eye and Ear Infirmary of Mount Sinai.
The Mount Sinai Health System is an equal opportunity employer. We promote recognition and respect for individual and cultural differences, and we work to make our employees feel valued and appreciated, whatever their race, gender, background, or sexual orientation.