Outreach and Patient Engagement
- Identify and engage patients at risk for or are diagnosed with cardiovascular disease (CVD), focusing on moderate-risk individuals.
- Provide culturally responsive education on cardiovascular health, risk reduction, self-management strategies and program benefits.
- Assist patients with appointment scheduling, reminders, and transportation arrangements.
- Conduct proactive outreach to patients who miss visits or are overdue for follow-up to reinforce care plans and reduce missed appointments.
- Build trusting, ongoing relationships with patients, acting as a consistent point of contact to support adherence to care plans and promote self-management and adherence.
Health Education and Coaching
- Provide health coaching on lifestyle modifications, including healthy eating, physical activity, stress management, smoking cessation, and medication adherence.
- Support patients in using digital health tools (e.g., home blood pressure monitors, smartphone-enabled ECGs, remote patient monitoring devices).
- Use motivational interviewing and teach-back methods to reinforce provider and care team guidance and instructions and confirm patient understanding.
- Provide ongoing encouragement and support for sustainable lifestyle changes.
- Deliver linguistically and culturally tailored materials to ensure accessibility and patient understanding.
Referral and Resource Coordination
- Conduct Social Determinants of Health (SDOH) screenings using standardized tools (e.g., PRAPARE).
- Document findings in the electronic health record (eClinicalWorks) to inform care planning and referral processes.
- Refer patients to enabling services and community-based resources (e.g., food assistance, housing, transportation, legal aid).
- Collaborate with community-based organizations and agencies to establish seamless connections between patients and SDOH resources.
- Provide follow-up to ensure referred services are accessed, using a bi-directional referral system to support closed-loop referrals and confirm completion of services.
Care Team Collaboration
- Actively participate in care coordination huddles with providers, Case Managers, Pharmacists, Nutritionists, and Behavioral Health staff.
- Communicate patient progress, barriers, and social needs with the care team, ensuring coordinated, whole-person care.
- Serve as a bridge between patients, the cardiovascular care team, and community partners.
Documentation and Quality Improvement
- Maintain timely, accurate documentation in eClinicalWorks, including encounters, referrals, and follow-up activities.
- Assist in chart reviews for quality assurance purposes as requested.
- Assist with data collection and reporting requirements for program evaluation and quality improvement initiatives.
- Participate in QA/PI initiatives, including Plan-Do-Study-Act (PDSA) cycles and staff trainings.
- Support dissemination of program outcomes and lessons learned through patient stories and feedback.
- Perform other duties as assigned to ensure the success of the Center for Justice in Cardiovascular Health.
