The Care Coordinator (CC) is a part of the Connect 2 Care Team that works to engage multiple systems of care to provide an integrated and coordinated approach to improve overall medical and behavioral health outcomes for HIV positive clients. The CC is part of a team that consists of medical and non-medical care staff and may be required to work non-traditional business hours to meet the demands of this program. The CC’s primary role is to provide and support rapid linkage to newly diagnosed persons and to those who are chronically disengaged from medical care in retention in effective and sustainable HIV treatment. Together they will be addressing the multiple barriers to accessing or staying retained in medical care.
ESSENTIAL DUTIES AND RESPONSIBILITIES:
Provide care coordination services to a caseload determined by the Linkage to Care Program Manager, including: completing an in-depth baseline psychosocial assessment aimed at identifying barriers to care, facilitating referrals to primary care, facilitating referrals to essential services that the client may need to access or stay retained in care, assisting with scheduling and preparing for appointments, providing appointment reminders, providing clients with in-depth adherence counseling and emotional support to assist in overcoming their barriers to engagement in care, implementing ARTAS and CLEAR, accompanying clients to appointments and maintaining contact with clients until retention in care can be confirmed.
Provide ongoing and professional communication with clients’ treatment providers (e.g. Infectious Disease provider, social worker, medical case manager), including participating in case conferences.
Ability to build relationships and networks with other CBO’s and medical facilities.
Maintain comprehensive documentation and reporting on clients and retention-in-care activities in program database and records.
Utilize harm reduction, trauma-informed, and LGBTQ affirming strategies in working with clients.
Adopt and implement continuous effective engagement strategies throughout intervention period, such as texting and home visits, to maintain client’s participation in program and evaluation activities.
Assess client need and interest in receiving ancillary services, such as Ryan White or DRS Case Management, behavioral health, and housing services and facilitate referrals.
Collaborate with testing, linkage, and retention staff and interns in the ongoing development and evaluation of the Connect 2 Care program, including providing feedback to the Linkage to Care Program Manager on aspects of the intervention that are/are not effective, and the co-creation of intervention tools such as assessment forms and participant handbooks.
Attend trainings to build competency around areas such as HIV/AIDS treatments and care, cultural competency in serving transgender and gender non-conforming individuals, retention-in-care strategies, harm reduction, and trauma-informed interventions.
Participate in bi-weekly Connect 2 Care staff meetings, as well as monthly H.O.P.E Department staff meetings and other agency-wide meetings when appropriate.
Meet weekly with Program Manager for administrative and clinical supervision.
Perform other duties as assigned.
Demonstrates experience providing direct clinical services with highly vulnerable, difficult-to-engage populations is required.
Bachelor’s degree in social work, counseling or related field strongly preferred, or equivalent training and experience.
Working knowledge of HIV/AIDS and the HIV/AIDS service network strongly preferred.
CDC interventions ARTAS and CLEAR certification preferred but not required.
Strong leadership, communication, organizational and interpersonal skills with a diverse range of individuals, organizations, and communities required.
Familiarity with harm reduction, LGBTQ affirming, and trauma-informed philosophies of care strongly preferred.
Ability to work outside of regular business hours
Willingness to travel throughout the Chicago metropolitan area required; ownership of a vehicle with valid Illinois driver’s license and insurance preferred.
Internal Number: CC 10082019
About Chicago House and Social Service Agency
Chicago House was founded in 1985 by a small group of community activists who saw that their friends and family members were losing their homes due to the financial, social and medical challenges associated with HIV/AIDS.
To provide community-based housing and supportive services responsive to the changing needs of individuals and families living with HIV/AIDS.
All Chicago House services are provided without discrimination, and are explicitly designed to respect and preserve the dignity and independence of all clients.