• Outreach/Engagement Activities:
• Use evidenced based outreach strategies to continually engage with clients and link them to healthcare.
• Initiate patient tracking via internal database and resident roster.
• Proactively reach out to patients requiring follow up by working with housing-based case manager, medical providers, and mental health providers.
• Engage and support patient family and significant others as clinically appropriate.
• Use effective communication skills such as active and reflective listening to build rapport with vulnerable and difficult-to-engage clients, including clients who have experienced chronic homelessness.
• Proactively engage in outreach activities for Enhanced Care Management eligible patients by conducting outreach calls, meeting with patients during appointments, and ensuring providers are up-to-date on eligibility for the program.
• Participate in partnerships and coalitions with other community providers to increase the portfolio of partnerships accessible to the CC Department.

• Provide immediate assistance to patients as needed, including locating emergency shelter, food resources, etc., based on internal on-call Care Coordination schedule.
• Apply critical thinking skills and sound decision-making capabilities, often under pressure, in complex situations as needed.
• Interview and assess clients to identify biological, psychological, social, and economic factors which may interfere with attaining stability and optimum health.
• Proficiency in implementing effective strategies for engagement and rapport building.
• Demonstrable expertise in condition(s), and evidence-based strategies to address condition(s), common in the patient population, including Domestic Violence, Substance Use, Mental and/or Physical Health Condition(s), Re-Entry, Chronic Homelessness, etc.
• Evaluate each client’s past, present, and future medical, psychological, social, and economic functioning as indicated.
• Assess each client’s stage of change and readiness for self-management.
• Expertise in administering structured assessments, including assessments on Social Determinants of Health, to gather, track, and assess client progress.
• Understanding of the Coordinated Entry System protocols and administration of the VI-SPDAT tool for individuals.

• Utilize information obtained from completed assessments, client input, and multidisciplinary team to formulate and develop comprehensive, individualized, and person-centered care plans that are based on the needs and desires of each client and that incorporate each client’s physical health needs, behavioral health needs, social service needs, including any community-based LTSS;
• Monitor status and completion of care plan objectives; and
• Reassess individualized care plans based on each client’s progress and/or changes in their needs.

• Coordinate and facilitate effective communication among providers.
• Engage and initiate case conferencing with the multidisciplinary team as needed.
• Utilize appropriate motivational interviewing interventions to effectively address each client’s current stage of change.
• Apply clinical and behavioral interventions, such as motivational interviewing, that decrease and, if possible, prevent complications as well as optimize disease control and patient well-being.
• Apply Harm Reduction strategies to engage with residents, including participation and certification in Narcan training.
• Provide accompaniment services to clients as needed, determined by patient assessment and interviews.
• Utilize strengths-based, solution-focused strategies to assist patients.
• Create SMART goals in collaboration with patients.
• Promote self-management skills for each client to demonstrate an ability to effectively engage with health and service providers as well as to achieve self-directed, individualized health goals that promote recovery, improved functional and/or health status, and/or prevent or slow declines in functioning.
• Engage in additional care coordination activities as indicated, which may include:
• Monitor and encourage treatment adherence/compliance by clients;
• Managing referrals, coordination, and follow-up for identified services and supports; and
• Coordinate discharge/transition of care, which can include working with hospitals to create a process for prompt notification of each client’s admission or discharge to/from an emergency department, hospital inpatient facility, residential/treatment facility, or other higher-level of care facility.
• Ensure appropriate care at the level of care transitions by providing evidence-based transition planning, which may include
  • Planning related to the timely scheduling of follow-up appointments with recommended outpatient providers and/or community partners; and
  • Supporting clients and each client’s support system during discharge from hospital and institutional settings.
• A clear understanding of nonprofit and community resources landscape to effective link clients to appropriate services, including:
• Maintenance of housing;
• Substance abuse treatment;
• Mental health care;
• Obtaining basic needs; and
• Public benefits.
• Provide client assistance with requesting copies of birth certificates, identification, public benefits information, and other documentation as needed.
• Substance abuse referrals:
• Complete substance abuse referrals for the indicated level of care, such as inpatient detox, outpatient individual/group treatment, and residential treatment, per existing protocol.
• Mental Health referrals:
• Complete mental health referrals for the indicated level of care/service, such as FCCS and FSP as needed.
• Collaborate with on-site mental health practitioners to ensure an adequate level of services.
• Conduct suicidality assessments and engage subsequent workflow to provide emergency assistance to patients based on mental health status and risk.
• Public Benefits linkage:
• General Relief (GR);
• CalFresh (food stamps);
• IHHS;
• CBEST;
• Supplemental Security Income (SSI);
• Social Security Disability Insurance (SSDI);
• Medi-Cal enrollment; and
• Veterans Administration benefits for eligible homeless individuals.
• Ability to work in groups as well as self-guided, independent Care Coordination.

• Ensure each client is knowledgeable about their condition(s), by providing culturally appropriate information that meets health literacy standards, in order to encourage and promote adherence to treatment.
  • Create health education courses to bolster training materials for the department.
  • Provide health education on appropriate and condition-related topics, such as nutrition, diabetes management, and treatment compliance.
  • Provide education and support for each client and identify support systems to attain and improve self-management skills.
• Assist each client with goal-setting and problem-solving behaviors for improved self-management.
• Assist each client with locating and obtaining transportation to/from appropriate medical and/or social service appointments.
• Utilize all resource directories needed including 211, Aunt Bertha, SPA 4 resource sheets, and LACHC-specific resource guide.
• Utilize, maintain, and update the LACHC resource guide as changes occur and keep resource information on hand to give to clients and providers for all applicable resources.

• Participate in case conferences to:
• Ensure that all identified biopsychosocial areas, including environmental factors, are addressed with care coordination and medical treatment planning;
• Ensure that each client’s care is continuous and integrated among all service providers; and
• Coordinate activities and communication among each client’s multi-disciplinary treatment team.
• Promote timely processing of each client’s subspecialty referrals;
• Communicate with internal departments and/or outside care agencies as well as IPA/health plans, as applicable, to initiate referrals and to ensure appointment obtainment.
  • Record requests for these referrals/appointments.
• Coordinate with authorizing and prescribing entities as necessary to reinforce and support each client’s health goals.
• Accompany identified clients to critical appointments as appropriate.
• Enter all appropriate data into the Homeless Management Information System (HMIS), following the criteria set out by HUD for data elements and the workflows set by the Los Angeles Homeless Services Authority (LAHSA).
• Utilize and improve internal tracking systems to accurately capture Care Coordination progress within the assigned roster.
• Attend community meetings, such as CES case conferencing, advocacy efforts, and service planning area providers meetings.
• Document all evaluations, care plans, interventions, and referrals performed per established EHR processes.
• Synthesize complex information obtained from assessments, training, and research to implement up-to-date, evidence-based interventions for impactful Care Coordination.
• Participate and obtain certification in LA Care’s training academy for Care Coordination practices.
• Participate and obtain certification in ongoing training topics as assigned, including, but not limited to Motivational Interviewing, De-Escalation Strategies, Fair Housing, Trauma-Informed Care, Safety Planning, Accompaniment, Case Management Core Functions.
• Other duties as assigned.

• CPR Certification required.
• Bi-lingual Spanish preferred

Los Angeles Christian Health Centers opened in 1995 with a handful of staff but a big vision to render hope and healing through healthcare to the thousands of homeless and low-income residents living in Los Angeles County. Today, 120 staff members serve the County’s most vulnerable populations from our two full-time health centers in Skid Row and Boyle Heights. We also provide comprehensive medical care at our 10 part-time satellite clinics hosted by our community partners throughout Downtown Los Angeles and Watts.