Serious Illness Community Liaison

SUMMARY: The Serious Illness Community Liaison raises awareness and identifies individuals requiring palliative care in the community; provides support for therapeutic management of pain; engages holistic home-based care delivery and visitation; and provides psychological support and spiritual connection. Primarily focused on outpatient palliative care, the SICL works to identify culturally contextual barriers to care and elevate them with community partners to identify gaps in services and develop a continuum of services for palliative care.

DUTIES & ESSENTIAL JOB FUNCTIONS: NOTE: Following are the duties performed by employees in this classification. However, employees may perform other related duties at an equivalent level. Not all duties listed are necessarily performed by each individual in the classification.

1.  Manages outpatient palliative care resources and maintains positive community relationships.

2.  Supports with coordination and preparation of outpatient clinic.

3.  Attends weekly interdisciplinary team (IDT) rounds and contributes to patient discussions as appropriate.

4.  Participates in developing structures and functions to support the palliative care team’s assignments and volumes.

5.  Assists team members in coordinating services provided by palliative care and other health care team members including nursing, physician, and care management teams.

6.  Assists with identifying programmatic opportunity gaps and works to find a reasonable client centered solution.

7.  Documents non-clinical assessments and reports moderate to distressing symptoms to outpatient palliative care team.

8.  Assists in determining achievable goals in the context of serious illness care.

9.  Identifies family caregivers at risk for burnout and assists in resiliency planning utilizing community resources including respite care.

10. Provides education to patients and their families about palliative care, advance care planning, services available at Alameda Health System.

11. Maintains patients records and documents palliative care services in the electronic health record.

12. Assist with data collection and analyzation in accordance with the grant.

13. Conducts home visits and meets with clients in the community Coordinates patient logistics for care, such as arrange rides, appointment reminders, obtain medical records, communicate with specialty clinics, and care team consult.

14. Serves as a bridge between medical staff and patients to address emotional, behavioral, and financial barriers.
 
15. Administers surveys to collect pre and post services data that informs the work in the outpatient clinic

16. Provides medical system navigation, resouce support to patients and their families. 

17. Serves as a integral part of the care team and participates in family meetings and end of life discussions.

18. Serves as the community liaison to identify community and resource gaps using a client centered, trauma informed, and holistic approach to care to assist patients.

MINIMUM QUALIFICATIONS:

Licenses/Certifications: Valid California driver’s license.

Preferred Education: Bachelor’s degree in a related field (health, social science or a related field such as psychology or counseling) or an emergency technician program.

Required Education: High school diploma or G.E.D.

Required Experience: One year of progressively responsible work experience in a community-based health care service capacity;   or the equivalent of two years of relevant full-time experience working in a community outreach program performing similar duties; experience with Electronic Health Records (EHRs)  

Preferred Experience: One year working in a community outreach program performing duties such as intake, peer counseling, assessments, program screening, placement and referral. Experience working in palliative care or hospice environment; Experience with peer counseling.