Paramedic/ Boston Medical Center Navigator

Job Description: This is a hybrid role that will split time between dedicated duties inside Boston Medical Center as a patient navigator and in the field as an Advanced Community Care Clinician. As a BMC navigator, they will support the coordination of care and reduce unnecessary acute care use for Cityblock Health (CBH) members at Boston Medical Center (BMC). The BMC Navigator will act as a crucial link between the BMC and Cityblock Health teams, facilitating seamless communication and care transitions. As an Advanced Community Care Clinician they will be responsible for delivering medical care in the communities where Cityblock members live. In homes, shelters, offices, public places or in the street. The ACCC/AC3 will facilitate virtual provider visits with Cityblock members and following medical orders, perform clinical skills and tasks within their scope, training, and policy. These may include, IV insertion, IV/IM/SQ medication administration, 12 EKG, Phlebotomy, and others dependent upon local legal regulations.

Responsibilities AC3 Workflow Cityblock delivers integrated primary and acute medical care, behavioral health and social care, powered by relationships and designed to advance equity in access and outcome. By delivering these acute and longitudinal services in-home through a combination of digital and in-person connections, we can allow members to stay at home and out of the hospital. The Advanced Community Care Clinician is pivotal in connecting members to Cityblock services including medical providers and access to all Cityblock services. There are several primary visit types they will be responsible for: ED@home: Acute illness facilitated provider visit Facilitated Visit: Longitudinal care team facilitated provider visit Outreach: Independent visit to find hard to reach members Specimen Collection: Independent visit to obtain tissue samples for the lab. MIC Only Follow-up: Independent visit with a specific set of visit goals Each shift the Advanced Community Care Clinician will begin their day reviewing their equipment, communications, and scheduled visits. They will plan to integrate mandatory training, meetings, and lunch into their day at pre-planned times or in any down time. Before the visit they will review Commons and Athena for any warning or instructions about the visit. Review the need for written consent. Arrive 10 minutes prior to the start of the visit and make member contact. Introduce themself and describe how a visit is conducted Complete required charting and activities prior to bringing the virtual provider on video. Use the Cityblock computer to facilitate a video visit. Carry out any instructions like order or examinations, sometimes on camera and sometimes independently as instructed. Post visit they will complete documentation, process lab work in a centrifuge and decontaminate their equipment. They will then get themselves set for the next visit by restocking and preparing equipment. Their vehicle whether Cityblock owned or personal; will be kept, maintained and used in accordance with company policy. Boston Medical Center (BMC) Navigator Workflows: Daily Census & Communication: Each morning, review the daily ED/inpatient census at BMC to identify Cityblock members who are currently in the ED, admitted inpatient, or who presented/were admitted during off-hours. Post the daily census in the designated BMC Navigator Communication Slack channel, and @mention the primary care manager and Resource RN. Review member profiles in Cityblock’s platform, Commons, to understand their clinical picture and available resources. Document all member interactions and findings in Commons and in the BMC EPIC system based on internal protocols. Emergency Department (ED) Workflow: Receive and respond to notifications of new ED presentations via the Bamboo Health alert system. Communicate with the Cityblock Care Manager, Resource RN, and CBH Provider via Slack upon a member's ED presentation. For Consented/Enrolled Members: Work with a Cityblock designee to determine if a member needs an HRA or CORE assessment. Conduct a medical/behavioral health/social/systems screening with the member in the ED and share findings. Discuss hospital-at-home capabilities with ED providers, add notes in EPIC, and facilitate a call between the Cityblock Provider and the ED attending to discuss diversionary planning (e.g., same-day provider or paramedic visit). For Not Yet Enrolled Members: Connect with the member to explain Cityblock services. Assist them in signing consent forms, coordinate with Cityblock via Slack to schedule assessments, document outreach, and complete the Long Term Services Coordinator Tool. Prior to ED Discharge: Reconnect with the Cityblock provider to discuss the discharge plan, review instructions with the member/caregiver(s), provide welcome packet materials, and educate the member on Cityblock's services. Inpatient (IP) Workflow:For Consented/Enrolled Members: Connect with inpatient case management and the member to review the plan of care and discharge plans. Obtain needed information and assist with requesting services or Durable Medical Equipment (DME). Facilitate communication between the Cityblock provider and the inpatient medical team.• For All Members: Attempt to connect with hard-to-reach members. Explain Cityblock services to unconsented flagged members and assist with consent. Upon consent, schedule a 7-day post-discharge TOC (Transition of Care) home visit. Ensure the member receives the discharge packet.