Social Medicine Associate

Social Medicine Associate is responsible for partnering with the care team and members to:

Assists members in navigating and accessing community services/resources. Plans and coordinates functions and activities related to meeting the psychological, social, and nursing needs of patients and their families. Supports the interdisciplinary team by coordinating care for patients when discharged to the community. Serves as a liaison between treatment team and patient through an integrated approach to care management and community resources. Performs duties in accordance with all regulatory requirements as well as policies and procedures of Kaiser Permanente.

• Provides supportive services to the continuing care team to assist with discharge and long-range planning.
• Support members in resolving potential issues related to health care delivery, financial or social barriers.
• Assist members in navigating services based on medical, social, and psychosocial needs.
• Assist in the completion and notarization of Advance Health Care Directives (AHCD).
• Coordinate and referral of services for patient, to include but not limited to, KP services: IBH, PFS, KPQI, TCC, SWITCH etc. outside agencies for community resources: Case Management Agencies, Nursing Facilities, Hospice agencies, transportation, interpreter services etc.
• Assist patient with completing documents required for services.
• Assists with the coordination of follow-up appointments, post discharge from acute care setting.
• Works collaboratively with multidisciplinary team through team meetings to ensure patients are receiving quality care.
• Attends and participates in scheduled staff meetings and training sessions.
• Maintains required documentation using KPHC electronic health information.
• Assist with resource development and able to network with other community-based services.
• Participates in routine data collection and administrative duties in a timely manner: Maintaining necessary logs, affiliated care providers list, community resources and other data collection as assigned.
• Uses good judgement and discretion to support licensed providers and appropriately documents actions taken.
• Provides services that are within scope of role and maintains compliance with all legal, regulatory, and policy requirements relevant to role performed.
• Incorporates the KP Vision, Model and Values throughout their practice.
• Performs other duties as assigned.