ORGANIZATION
The mission of Ravenswood Family Health Network (RFHN) is to improve the health of the community by providing culturally sensitive, integrated primary and preventative health care to all, regardless of ability to pay or immigration status, and collaborating with community partners to address the social determinants of health.
POSITION SUMMARY
The Pediatric Health Coach, as a member of the clinical care team, assists in the identification, tracking, and education of specific pediatric patients and their families who benefit from directed health education and need recommended screening or follow-up, or whose chronic disease management requires increased care coordination. The Pediatric Health Coach applies knowledge specific to pediatric growth and development, chronic diseases, and recommended screenings in order to support change in health behaviors for patients and their families. The Health Coach applies motivational skills when needed to parents or children and teens, when appropriate.
DUTIES AND RESPONSIBILITIES
To be performed in accordance with RFHN Policies and Procedures
- Works closely with the patient’s care team in meeting the organization's health management goals.
- Implements department workflows to identify patients with clinical care gaps or due for recommended care, and coordinates outreach directly or indirectly to schedule and complete care, including (but not limited to):
- Immunizations due or overdue
- Well Child Checks due or overdue
- Screenings due, such as developmental screens (ASQ, MCHAT), lead, depression, sexually transmitted disease, etc.
- Persistent asthmatics in need of visits, school forms, action plans
- Overweight, obese, or prediabetic patients in need of visits, lab work, or referrals
- Diabetic patients in need of recommended screenings
- Implements department workflows to identify patients with operational needs and coordinates outreach directly or indirectly, including (but not limited to):
- New patients in need of establishing care
- Out of care patients in need of returning to care
- 18+ year old patients in need of transition to adult care
- Patients with positive screening for social determinants of health (SDOH) in need of connection to social services or community services
- Provides both individual family and group meetings to assist in behavioral change to improve health status, reduce health risks and improve quality of life. Facilitates group sessions that introduce families to the care model, the family or patient’s role in achieving healthy lifestyles, and helping families set and achieve goals for management of common pediatric chronic diseases such as asthma, obesity, prediabetes, allergies, and others.
- Counsels and advises patients on common medication management issues such as how to correctly dose pediatric medications, how to refill medications, and instructs to bring medications or medication list to all appointments.
- Communicates using motivational interviewing and engagement strategies.
- Communicates with patients and families in a positive, respectful and empathetic manner, and motivates patients to set goals for managing their self-care based on what matters to them.
- Conducts active panel coordination for patients with chronic diseases in order to address care gaps; assures care provided at outside facilities is completed.
- Works within the scope of the health coach role and does not provide medical advice or care that is the scope of licensed health care professionals.
- Performs other duties as assigned and requested.