Care at Home Community Navigator

Job Summary:

The Kaiser Permanente Care at Home (KPCAH) Care at Home Community Navigator (CAH CN), in conjunction with the other members of the agency admission care team, is responsible for activities and actions related to promoting the services and expertise of Hospice to patients and family members and to the community. The CAH CN requires the individual to customarily and regularly work within Kaiser Permanente (KP) and externally with the community to establish and promote Hospice services and coordinate care to assure smooth care transitions for utilization of KP Care at Home Hospice.

Essential Responsibilities:

• The KPCAH CAH CN is responsible for:
• Hospice program optimization develops and increases access to KPCAH Hospice services for Kaiser Permanente members within the appropriate agency service areas.
• Cultivating positive relationships with KP staff, members, internal and external customers, and existing and potential partners within the community.
• Responding to customer and community needs regarding community education as it relates end-of-life Hospice care services.
• Clinical Operations:
• Serves as a liaison between physicians, KP medical centers, KP contracted hospitals, skilled nursing facilities (SNF), community living (Assisted Living Facility (ALF) and Care and Foster Homes and assists with coordination of referrals/admission process and services, and resolution of patient issues.
• Provides patient and family with information and resources on Advance Directive/POLST and coordinates follow-up with MSW as needed.
• Responsible for KPCAH referral processes for Hospice, which includes:
• Responds to inquiries, requests for information, and follows up on referrals for admission,
• Provides information on programs and benefits.
• Engages a colleague to enter orders/referrals in the electronic health record. For internalized hospice referrals, coordinates DME, medication, inclusive of home infusion medication and pumps with Agency/Team.
• Coordinates care with ALF, Care Home and SNF, as above.
• Ensures documentation is complete in the electronic health record.
• Coordinates start of care with designated Agency representative to coordinate start of care then alerts patient/family and others (i.e., SNF, Care Home, ALF, etc.) to timeline as needed. Consults with KPCAH Agency Director of Patient Care Services/designee and/or Clinical Supervisor as needed.
• Provides patient/family education related to KPCAH philosophy and available services.
• May assist in securing the completion of requisite forms, such as Election of Benefit (BOE); documents Health Care Agent (family member, DPOA, conservator); identifies mortuary, if known.
• Participates in medical center rounds (Care Without Delay (CWD), Inpatient Palliative Care (IPC), etc.) to proactively identify and assist with Hospice eligible patients and their families with care transitions at the right place and right time.
• Participates in IDG meetings and works with the IDG to determine the patient/family plan of care as needed.
• Exhibits excellent customer relations to patients, visitors, physicians, and co-workers; shows courtesy, compassion, and respect.
• Conforms to the critical service standards established for the department and the medical centers.
• Administrative/Community Education:
• Engages in weekly community outreach with Admissions Coordinators and Business Development leaders at the contracted SNFs and surrounding residential care facilities to relationship build and facilitate timely Hospice placement.
• Provide hospice education to contracted SNF/ALF/B&C facilities when applicable.
• Maintain a comprehensive working knowledge in the field of community educational resources and share information with appropriate organizational personnel. Regularly ensure community education needs are met through assessments and strategies designed to meet community services as determined.
• Establish and provide feedback about community, customer, and payer and patients perceptions of Kaiser Permanente Hospice as a high-quality provider in the community.
• Identifies risk factors for community and family needs and makes appropriate referrals to agency activities as assigned. Actively participate in the Quality Assurance Performance Improvement (QAPI) process as directed by the Area Administrator and/or Director of Patient Care Services. Upholds Kaiser Permanentes Policies and Procedures, Principles of Responsibilities and applicable state, federal and local laws.
• Performs other duties as assigned.