The Housing Health Advocate reflects the mission, vision, and values of NM, adheres to the organization’s Code of Ethics and Corporate Compliance Program, and complies with all relevant policies, procedures, guidelines and all other regulatory and accreditation standards.
Responsibilities:
- Provides case management and support to patients with chronic illnesses in order to assist them in achieving medical and social stability.
- Provides these services in both the community and in an outpatient clinic to ensure maximum flexibility.
- Initiates clinical contact with adults with chronic medical illness to engage them in setting and achieving measurable goals related to their health care needs throughout various hospital locations.
- Assists patients to identify and obtain appropriate medical and social services; advocates with these agencies for patients; as needed.
- Assists patient connect to federal entitlement appointments via public transportation as needed.
- Actively participates as a member of an interprofessional team; working with physicians, pharmacists, social workers, therapists, and psychiatrist to provide comprehensive patient care.
- Proactively collaborates with other Northwestern Medical Group programs as well as other community-based referral sources to ensure seamless coordination of patient care.
- Documents timely, accurate and appropriate clinical information in patient’s medical record.
- Documents tracking information and clinical data for patient tracking and research purposes.
- Provides coverage for the other Health Advocates, and members of the transitional care team when necessary; possesses the knowledge and experience to competently handle these responsibilities.
- Performs evaluation of the physical environment and adequacy of support systems to prevent a crisis and/or hospitalization.
- Utilizes advanced problem-solving skills and creativity to coordinate action plans when barriers are present.
- Utilizes conflict resolution skills as necessary to ensure timely resolution of issues and system problems.
- Seeks consultation from and makes referrals to appropriate disciplines/departments as required to meet the goals outlined in the patient’s Health Improvement Plan.
- Demonstrates knowledge of community resources and an ability to connect patients and families with these resources.
- Provides patient and family education that promotes wellness and increases knowledge of the health care system.
- Complies with Northwestern Memorial Hospital policies on patient confidentiality including HIPAA requirements and Personal Rules of Conduct.
- Displays sound judgment when conducting visits to patients in diverse communities.
Additional Responsibilities: Emergency Department Transitions Hub Support and Care Coordination
- Serves as the primary Northwestern Medicine representative within the Emergency Department (ED) Transitions Hub, establishing trusting and therapeutic relationships with patients experiencing homelessness and other complex social needs.
- Engages high-utilizing ED patients and facilitates warm handoffs to community partner organization (CPO) staff providing intensive case management, housing navigation, and supportive services.
- Collaborates closely with interdisciplinary care teams, social work, and community partners to develop individualized transition plans that address medical, behavioral health, and social determinants of health needs.
- Supports patients throughout the transition process by assisting with completion of required documentation, benefit applications, housing assessments, and other activities necessary to secure emergency shelter, transitional housing, or permanent housing resources.
- Coordinates transportation and logistical arrangements to ensure safe and timely transitions from the hospital to community-based services, shelters, housing programs, and other destinations.
- Maintains ongoing communication with community partner organizations to monitor patient progress, remove barriers to placement, and promote continuity of care.
- Tracks patient disposition, program outcomes, and transition milestones, ensuring timely, accurate, and complete documentation within the electronic medical record.
- Identifies and escalates barriers impacting successful patient placement and collaborates with internal and external stakeholders to develop solutions.
- Demonstrates knowledge of housing, homelessness, and community-based support resources and actively advocates for patient access to these services.
- Supports continuous improvement efforts by providing feedback on workflows, patient experience, community partnerships, and operational processes within the ED Transitions Hub.
- Provides longitudinal support and follow-up for patients awaiting housing placement, deemed ineligible for housing programs, or not yet ready to pursue housing resources, ensuring ongoing engagement, reassessment of needs, connection to alternative community supports, and continuity of care across settings.