Integration Specialist (BA)

Sea Mar Community Health Centers, a Federally Qualified Health Center (FQHC) founded in 1978, is a community-based organization committed to providing quality, comprehensive health, human, housing, educational and cultural services to diverse communities, specializing in service to Latinos in Washington State.

Sea Mar proudly serves all persons without regard to race, ethnicity, immigration status, gender, or sexual orientation, and regardless of ability to pay for services.

Sea Mar's network of services includes more than 90 medical, dental, and behavioral health clinics and a wide variety of nutritional, social, and educational services.

We are recruiting for the following position:
Sea Mar is a mandatory COVID-19 and flu vaccine organization.

The Integration Specialist provides Health Home services and similar supports for patients whose complex medical, behavioral health and social concerns impede their ability for self-care. The Integration Specialist is a member of the patient-centered inter-disciplinary Care Management team, and has a strong understanding of chronic conditions and how each condition can compound another, leading to poor health outcomes. The Integration Specialist meets with patients in the location of their choice;

their homes, in the community, at in-patient settings or in clinics. This individual’s work will include timely and effective screenings and appropriate referrals to internal Sea Mar service providers, community-based resources, and emergency services when indicated. Screenings may pertain to functional abilities, daily medical self-management skills, fall risk, depression, anxiety, drug and alcohol use, and other screenings when indicated. Through the use of motivational interviewing and other techniques, the Integration Specialist will work with the patient to create a Health Action Plan which includes long and short term goals with actionable steps that will help the client self-manage their chronic health conditions.

As part of ongoing services, the Integration Specialist will follow up with the patient regularly to evaluate progress made towards completing their Health Action Plan goals. As part of the Care Management/ Health Home six core services, the Integration Specialist provides care transition assistance from in-patient settings, follow-up in the home, as well as community based care coordination, health promotion, patient and family support, referral to community and social support services, and comprehensive care management.

As part of the clients’ interdisciplinary team, the Integration Specialist will provide information and recommendations regarding the client’s care.

• Prior to HAP, reviews screenings and electronic record and when appropriate reaches out to other service providers with whom patient has had contact to consult how to best support patient goals and ensure non-duplicative efforts.
• Discusses with patient, family, caregivers, and providers (with consent) about treatment options and preferences; coordinates initiation of health action plan and on-going care coordination and care management.
• Conducts mandatory screenings and optional screenings when indicated by diagnoses or history to identify care needs.
• Creates a health action plan (HAP) with the patient which includes a long term goal, short-term goals, and small actionable steps to meet goals.
• Provides six core services in accordance with Health Home program requirements: health promotion, support to patient/family, care coordination, comprehensive transitional care, referral to social and community resources, care management.
• Monitors patient (in person or by phone) regularly for changes in severity of symptoms, changes in life circumstances compounding self-care abilities, and medication side effects and encourages patient to relay, or relays when needed, this information to the medical provider and/or specialists of other disciplines.
• Uses motivational interviewing and other techniques to help patients achieve HAP goals.
• Reviews health action plan and screenings with patient and/or family every four months.
• Actively engages patients and supporters…