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Department/Unit:

Medicine - Aids Program

Work Shift:

Day (United States of America)

Salary Range:

$65,102.17 - $100,908.37

The RAP specialist (RS) works closely with newly diagnosed HIV patients and patients demonstrating ongoing viral load (VL)greater than 200 copies/ml. The RS coordinates with the peer educator, RAP RN, and HIV provider to identify and address barriers to adherence and retention. The RS helps the patient with goal setting, self-management and skill development. Under the supervision and guidance of the manager of client services, the RS provides the following essential duties:

• Facilitates linkage to HIV care within three days of HIV diagnosis (rapid treatment)

• Completes the intake, initial needs assessment, initial service plan at the initial HIV medical visit. Assures patient receives information on partner services, HIV transmission, U=U, PrEP, HIV disclosure, etc, at the initial visit.

• Assures new RAP patients receive an orientation to the program, understand RAP expectations, and agree to participate. Documents these activities and patient’s agreement to participate in the program

• Assures timely follow up of patients initiating new antiretroviral therapy to assess for barriers

• Completes reassessments and service plan updates with the patient at least every 90 days. Assures service plans provide detailed action steps with corresponding target dates and responsible party

• Facilitates RAP monthly case conference meetings, assuring each RAP patient has a case conference within 30 days of enrollment and at least every 90 days thereafter. Ideally case conferences are coordinated with reassessments. Completes formal case conference documentation

• Provides retention interventions

• Serves as primary liaison to care teams outside of the immediate RAP program

• Refers to and coordinates with community support service providers and behavioral health providers on behalf of the RAP patient. Monthly contact with community case managers.

• Coordinates services to address medical care needs, as indicated

• Monitors HIV appointment scheduling and attendance, and reengages with patients who missed appointments

• Documents all patient interactions and care coordination efforts in the AMC electronic health record (EHR) and documents all services in AIRS promptly upon provision.

• Utilizes motivational interviewing in work with patients, applying the transtheoretical model for change, to assist patients with goalsetting, self-management, and other aspects of behavioral change

• Monitors patient status on elements such as STI screens, housing stability, household income, viral load, and risk behaviors, as required by funder

• Provides other client level information to data staff in accordance with grant requirements

• Facilitates crisis intervention as needed

• Communicates frequently with RAP team and supervisor regarding patient progress and needs

• Reviews caseload for patient’s meeting closure criteria and communicates this to supervisor. Coordinates with supervisor to assure closure note is entered to EHR and closure service is entered to AIRS

• Stays current on RAP guidelines, data entry procedures, and RAP work plan expectations, especially as they relate to the RS position

• Understands Ryan White eligibility expectations, completes initial eligibility form at firs t visit and every 6 months

• Maintains confidentiality in accordance with HIPAA and NYS HIV Confidentiality Law

• Participates in annual mandatory education and performance evaluations

• Complies with the Division of HIV Medicine and AMC center-wide regulations, policies, and procedures

• Participates in HIV quality improvement activities

Additional Responsibilities

• Develops collaborative relationships with HIV testing agencies to facilitate rapid treatment of their newly diagnosed clients as well as retention in care

• Reviews HIV program VL reports to identify potential RAP patients

• Provides occasional cross coverage of other case management functions, as needed

• Other duties as assigned by the manager of client services or designee

• Updates release of information forms, health care proxy, and other pertinent information annually

• Submission of monthly update reports to assist manager of client services with RAP monthly narratives.

COMMUNICATIONS SKILLS:

• Evaluates patient circumstances and communicates with the patient in an objective, nonjudgmental manner

• Addresses interpersonal conflicts in a direct and professional manner

• Responds promptly to email and phone messages; responds to routine inquiries or complaints from patients, regulatory agencies, or members of the community

• Reads and understands medical information

• Knowledge of medical terminology

• Fluency in written and oral English using the language in a proper and professional manner

• Fluency in Spanish is a plus

Part C

RESPONSIBILITIES: Provides case management services, as needed, to patients under the care of assigned providers. Ensures case coordination, effective use of resources and quality of care in accordance with the HRSA (Health Resource Services Administration) and Albany Medical Center case management standards by performing the following duties:

Intake/Assessment:

+ Conducts age appropriate interviewing with patients identifying needs such as adjustment to illness; financial/employment issues; food, clothing, or housing issues; substance abuse; physical/mental impairments to determine nature and severity of needs; understanding of HIV disease, transmission, and prevention; and behavior change issues.

+ Obtains information such as medical, psychological, and social factors contributing to patient's situation, and evaluates these in the context of the patient's strengths, limitations, and family situation.

+ Assesses and responds appropriately to persons in crisis, intervening to assure safety of patient and others, incorporating an understanding of legal responsibilities in cases of domestic violence and abuse issues.

Education and Supportive Counseling/ Intervention

+ Provides education on basic HIV disease concepts, transmission of HIV and sexually transmitted infections, community resources and other issues

+ Reviews patient’s prevention practices, partner awareness, and partner notification options

+ Assists patients in developing self-management and health literacy skills

+ Uses motivational interviewing to impact behavior change relating to HIV transmission, adherence to medications, and other issues

+ Provides cultural and age-appropriate supportive counseling, on a limited basis, to patient and /or social supports, as indicated, to address needs and mobilize inner strengths

+ Counsels patients in adjustment to life-threatening illness and its implications, acknowledging issues of diversity and adjusting intervention and practice accordingly

+ Uses education and collaborative goal setting to help the patient and family understand, accept, and follow medical and psychosocial treatment plans

+ Informs patients of consumer advisory board and other opportunities to provide feedback on program services

+ Understands legal issues regarding domestic violence, child abuse, and suicidal/homicidal ideation and intervenes appropriately and in accordance with Albany Medical Center’s policy and NYS law.

Care Coordination/ Interdisciplinary Teamwork

+ Assures annual psychosocial assessment via

+ Distribution of “Emotional Well-being Questionnaire” at annual comprehensive exam

+ Psychosocial assessment of patient needs at least annually for patients enrolled in grant funded programs

+ Develops, monitors, and updates the service plan annually and intermittently as needed. Formulates plans to include specific goals with distinct action steps, as indicated by needs assessment.

+ Reviews service plan and performs follow-up to determine quantity and quality of service provided to patient and status of patient's care with specific community providers.

+ Works in close collaboration with physicians and other members of the healthcare team to further their understanding of significant social and emotional factors underlying patient's health problem

+ Initiates and annually updates healthcare proxies/living wills with patient

+ Screens patient for eligibility to entitlement programs, community resources, and internal programs and refers patient to appropriate services/agencies based on identified needs.

+ Coordinates case conferences with medical and community agencies as needed.

+ Assists patients with retention in care

+ Obtains and updates authorizations for release of information to ensure inter-agency care coordination

+ Tracks patient status of Paps, annual comprehensive exam (ACE), dental care, and other medical indicators, and works with patients and care team to meet standards of care

+ Exchanges patient updates/plans with community case managers and provides medical outcome data to community case managers as requested

+ Communicates patient information/updates to AMC healthcare team using the EHR tasking feature

+ Refers pregnant patients to family program or Part D program. Attends OB case conferences (monthly) and monitors pregnant patients closely to ensure scheduling and follow up of prenatal and HIV appointments until family case manager assumes responsibility.

+ Meets with or contacts newly diagnosed patients at least quarterly for the patient’s first year in AMC HIV practice, unless this responsibility is covered by other case manager within the DHIVM. Interactions will focus on patient-identified concerns, retention, adherence, basic HIV education/transmission prevention/HIV resources and screening/addressing barriers to care

Documentation:

+ Documents assessments, service plans, case conferences, provision of taxi/pharmacy vouchers and other encounters directly in the electronic health record (EHR) or by submitting documents for scanning/filing to the secretary

+ Enters service data to the AIDS Institute Reporting System (AIRS)

+ Enters other information to AIRS including, but not limited to, referral, referral status, and pregnancy status

+ Completes authorizations for release of information with patients and submits for scanning in the EHR

+ Submits other pertinent documents for scanning to the EHR

+ Facilitates patient navigation of DHIVM and other medical systems, as needed

+ Completes documentation within 24 hours of encounter

Other Duties

+ Represents AMC/DHIVM in the community through tasks forces, community forums, and trainings as assigned

+ Maintains record of in-services, trainings, and ongoing continuing education for personal, professional and program development

+ Participates in ongoing supervision for continued professional growth

+ Participates in ongoing process improvement (PI) including, but not limited to, patient satisfaction survey, efforts toward meeting DHIVM PI goals, and individual PI project

+ Other duties as assigned or directed by the Manager of Client Services or other AMC management staff

+ Works closely with Manager of Client Services to assure appropriate program enrollments of each patient

+ Assures Ryan White eligibility determinations on all new DHIVM patients and 1-2 times annually on Part D, and Part C patients. Facilitates annual eligibility determination on other patients.

Communications Skills:

+ Evaluates patient circumstances and communicates with the patient in an objective, nonjudgmental manner

+ Addresses interpersonal conflicts in a direct and professional manner

+ Responds promptly to email and phone messages; responds to routine inquiries or complaints from patients, regulatory agencies, or members of the community

+ Reads and understands basic medical information

+ Knowledge of medical terminology

+ Fluency in written and oral English using the language in a proper and professional manner

+ Fluency in Spanish is a plus

ComPUTER SKILLS:

+ Typing

+ Basic PC skills, including navigation of hard drive, share drives/networks, internet, and email systems, accessing files and saving files to a variety of locations

+ Fluency in Microsoft Word

+ Ability to use Microsoft Excel documents

+ Ability to learn computer programs for scheduling, data entry, and medical record documentation

Mathematical Skills :

Ability to calculate figures and amounts such as discounts, interest, proportions, and percentages.

Reasoning Ability:

Ability to define problems, collect data, establish facts and draw valid conclusions.

Physical Demands:

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.

Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this job, the employee is regularly required to sit. The employee frequently is required to walk/move from one place to another. The employee is occasionally required to stand.

The employee must occasionally lift and/or move up to 10 pounds. Specific vision abilities required by this job include close vision and the ability to adjust focus.

The employee must be able to handle high levels of stress.

The employee is occasionally exposed to infectious diseases.

Work environment:

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. The noise level is the work environment is usually moderate and requires the ability to concentrate/maintain focus during potential distractions

Thank you for your interest in Albany Medical Center!​

Albany Medical is an equal opportunity employer.

This role may require access to information considered sensitive to Albany Medical Center, its patients, affiliates, and partners, including but not limited to HIPAA Protected Health Information and other information regulated by Federal and New York State statutes. Workforce members are expected to ensure that:

Access to information is based on a “need to know” and is the minimum necessary to properly perform assigned duties. Use or disclosure shall not exceed the minimum amount of information needed to accomplish an intended purpose. Reasonable efforts, consistent with Albany Med Center policies and standards, shall be made to ensure that information is adequately protected from unauthorized access and modification.