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Conducts needs assessment of clients with HIV/AIDS in the outpatient and
hospital setting for clients to receive comprehensive medical, social and
community resources on an ongoing basis or at least every 6 months. Conducts
home visits as needed to ensure timely access to and coordination of medical
and psychosocial services.
Conducts psychosocial assessments, developing, implementing and revising
individualized plan of care, family support plan and discharge plan on an ongoing
basis.
Educates, links and refers clients to follow-up medical care and community
resources to address needs in collaboration with other Ryan White Network
Providers. Advocates for client’s unmet needs, providing clinical intervention
(counseling, support) as needed.
Is familiar with appropriate sources of referral for mental health, substance
abuse, home care, food, transportation and other support services for people
living with HIV/AIDS. Provides referral assistance with above in addition to
insurance issues, Medicaid, Medicare, and other public assistance services.
Develops therapeutic relationships with clients, maintaining ongoing connection
with clients and families during times they are not accessing services. Assure
client awareness of all Ryan White programs and available community services;
advocate for accessibility for all services.
Provide linkages to agency, community and government services and monitor
referral completion including state insurance continuation programs, ADAP,
medication patients assistance programs (PAP), benefits/health coverage
programs such as PAC Waiver, SSI, SSDI, Medicaid, Medicare, housing
programs, etc.
Provides documentation of Ryan White service units and assists with monthly
and quarterly reports for internal and external grant sources. Maintains and
updates client records and notes utilizing a database system designed for
tracking of progress notes and other required information reporting as defined by
agency standards, including electronic medical record and/or CAREWare.
Attends weekly clinical staffing providing input regarding patient medical case
management needs. Attends other divisional meetings, as required, including
weekly research meeting, monthly Case Management Co-Op meetings, monthly
division meetings, and other meetings as required. All other duties as assigned.
Attends educational activities, trainings and events as required, including monthly
HIV Grand Rounds, Annual HIV Conferencing, Medical Case Management
training and other trainings as required. Actively participates in community
awareness and testing events including National HIV/AIDS Awareness, World
AIDS Week and other awareness events.
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