• Conducts assessment of Veteran in collaboration with interdisciplinary treatment team, the Veteran, family members and significant others
• Understand the Veteran’s situation, potential barriers to care, the causes and impact of barriers on ability to access and maintain health care services.
• Highlight the Veteran's strengths, limitations, risk factors and internal/external supports and service needs to optimize ability to access and maintain health care services.
• Assessment will be completed as specified by the policy of the SSVF Grantee
• Conducts initial assessments to determine program eligibility for SSVF and carries a small case load when called upon to provide housing assistance to Veteran clients in addition to regular Health Care Navigation Duties
• Acts as a health coach by proactively supporting the Veteran to optimize treatment interventions and outcomes.
• Serve as subject matter expert on community resources related to the needs of the Veteran.
• Determine needs, strengths, limitations and preferences of each Veteran.
• Advocate for the client, integrating the Veteran’s cultural values into care plan.
• Assists in identifying the Veteran and family's health education needs.
• Provides education services and materials that match the health literacy level of Veteran.
• Provides ongoing education support as needed to Veteran and family member.
• Assists in identifying VA and community resources to prevent disease and promote self-care.
• Identifies systemic barriers within the organization, communicates with organizational leadership about barriers and works collaboratively to find viable solutions.
• Assists in developing policy, procedures and practice guidelines related to the specialty program using knowledge gained from research or best practices.
• Develop evaluation components and outcomes indicators and report those evaluation results to VA and organizational leadership.
• Other duties as assigned.