Responsible for outreach to patients in identified communities who could benefit from support and navigation in accessing healthcare and wellness resources.
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Connects with patients via telephone, email or other forms of communication - that is tracked, monitored and effective. Encourages and supports patients to make concrete steps toward promoting their health and managing health conditions, per the patient's wishes.
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Collaborate with patients' care team members to ensure patient is connected to community-based and other resources that impact their overall health. Supports patient in meeting the requirements for community-based resources and identifying barriers to care, including transportation.
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Helps patients establish connection to primary care provider and schedule necessary appointments, if needed. Communicates with entire team to keep everyone focused on meeting patient-centered goals.
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Collaborate with Healthy Communities team members to build a robust network of community and healthcare resources for communities, neighborhoods and patient populations. Collects and helps analyze data from Cone Health and public data sources to identify and close gaps in care.
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Provide technical, logistical and navigation support to patients who are experiencing barriers accessing care either in face to face or virtual encounters.
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Actively participates in health equity and other meetings to provide input and feedback on needs and successful strategies for addressing health disparities and access to care in historically marginalized communities.