Health Advocate, Complex Care

About the role

At Accompany Health, we’re building the best model of care for patients with serious medical and social needs—people who are too often let down by the traditional healthcare system. As a Complex Care Health Advocate, you’re on the front lines of our mission to help patients stay safe, stable, and thriving at home.

You’ll visit patients in their homes to facilitate video visits, collect vital signs, complete social and clinical screenings, and support our interdisciplinary team—including primary care, nursing, behavioral health, pharmacy, and urgent care providers. You’ll help patients manage their conditions, follow through on care plans, and take proactive steps to avoid unnecessary hospitalizations—all while building trusted relationships that are the foundation of long‑term health.

Receive enhanced training to manage patients with complex physical and behavioral health.

• Build trusted relationships:
  Proactively engage with patients to build trust and provide support to hard‑to‑reach and highest‑needs patients so they stay healthier, longer, at home.
• Facilitate virtual visits:
  Set up, support, and/or conduct virtual visits with primary care or behavioral health clinicians or nursing, ensuring smooth technology use and readiness.
• Document, monitor and report patient status:
  Independently capture vitals, track changes in condition, and communicate early warning signs to the care team.
• Navigate social needs and insurance benefits:
  Identify and document social needs (food, housing, transportation, safety) and navigate patients through social resources and insurance benefits.
• Support complex care coordination:
  Support patient accountability with medication changes, referrals, appointment scheduling, testing, and home health services.
• Reinforce care plans:
  Coach patients and hold them accountable to self‑management goals, including medication adherence, diet, mobility, and mental health.
• Prevent avoidable hospital use:
  Recognize red flags and elevate promptly to nursing or urgent‑care partners to enable timely intervention.
• Deliver and support in‑home services:
  Deliver supplies, equipment, or medications following AH internal procedures and educate patients on proper use.
• Health
  
  Coaching:
  
  Support patients with setting goals, tracking behaviours and supporting through barriers that prevent patients from hitting their goals.
• Document and communicate effectively:
  Maintain accurate EHR documentation and consistent updates to the care team.
• Visit Accompaniment:
  Accompany patients to clinical visits for support with preventative screening and gap closures.

• Build trusted relationships:
  Engage proactively with patients experiencing SMI and SUD to build trust, reduce barriers to care, and support ongoing engagement.
• Support behavioral health visits:
  Partner with clinicians during medical and BH visits by collecting vitals and administering screenings (PHQ‑9, GAD‑7, PCL‑5, AUDIT, DAST, CIWA, COWS).
• Coordinate access to BH and SUD services:
  Guide patients through referrals and access to detox, rehab, methadone programmes, and community mental health services.
• Coordinate pharmacy care:
  Arrange medication delivery, verify access to MOUD (e.g., Suboxone), and schedule LAI and alcohol‑use‑disorder medication appointments (e.g., Vivitrol).
• Manage BH team operations:
  Schedule appointments for psychiatrists, Psych APCs, and BHCs, and ensure seamless coordination with the internal behavioural health team.
• Navigate community resources:
  Learn and maintain deep knowledge of local SMI/SUD resources while fostering relationships with community partners.
• Support transitions of care:
  Coordinate with inpatient psychiatry and medical hospital teams, including conducting in‑hospital care‑coordination visits.
• Reinforce behavioural health care plans:
  Support patients in managing medications, maintaining sobriety, reducing harm, and staying out of the hospital.
• Maintain a comprehensive resource directory:
  Update and organise local and national resources (mental health, SUD, housing, transportation, financial assistance, food access, medication discounts, support groups).
• Pe…