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Health Coach, Health Homes

​CAMBA's Health Home program is an innovative new model of care management focused on improving the health outcomes for individuals with severe mental illness & other complex chronic illnesses through coordinated networks of medical, psychiatric, behavioral health, social service & housing providers. Staff will use cutting-edge health information technology & a unified plan of care to ensure all clients connect to & maintain primary medical care, prevent hospital stays, &/or reduce the length of hospitalizations. CAMBA's participation in health home places it at the forefront of a broad system wide change that will have a significant impact on many human services sectors.


Essential Duties and Responsibilities:  The person filling this position is expected, under general direction, to: (1) provide individual counseling services to assist individuals to understanding health literacy; (2) counsel clients in dealing with such issues as: behavior, educational progress, family dynamics, mental and physical health, housing, personal finances, substance abuse, mental and/or physical trauma, etc.; including the following:    

  • Maintain professional relationships with clients and client confidentiality.
  • Practice Universal Precautions/Standard Protocol & Procedures.
  • Comply with any and all Federal, State, City and CAMBA security and privacy polices intended to protect the security and privacy of individually identifiable health information.
  • Work closely with Care Coordinators to identify clients with asthma and diabetes in their caseloads that could benefit from health coaching.
  • Complete asthma and diabetes assessment to identify triggers and risk level of clients and assist Care Coordinators in creating targeting interventions based on those assessments.
  • Coordinate care for clients identified with asthma and diabetes.
  • Make appointments for clients with diabetes to get required tests performed.
  • Document on the client's electronic record the interventions taking place with the client.
  • Create and maintain client files and make file copies.
  • Conduct trainings on asthma and asthma self-management to identified clients..
  • Consult/coordinate with others both inside and outside of CAMBA (i.e. other providers, primary care provider) to determine causes of client problems and effect solutions.
  • With clients' and/or client families' agreement, arrange for medical, psychiatric, educational and other tests and examinations that may disclose causes of client difficulties and indicate remedial measures.
  • Assist clients' and their families' to alter their attitudes and behaviors that cause or aggravate problems.
  • Assist clients in attaining their goals by identifying and locating community resources for clients and by making referrals to appropriate services both within and outside CAMBA.
  • Follow-up with clients and with referral organizations regarding client contact and progress with referral organization.
  • Monitor clients' progress toward their goals via regularly scheduled telephone contact and/or face-to-face home and office visits, and document via progress notes.
  • Provide all required information for weekly/monthly/quarterly/annual reports.
  • Follow-up with clients for a period of time after successful completion of their primary goals to assure client stability.
  • Recommend closing of cases in which clients have: (a) achieved primary goals and have maintained stability for a period of months; or, (b) have not demonstrated a willingness to participate in the process (lost-to-service); or, (c) have become ineligible for services (e.g. moved out of area).
  • Input client data and client progress information into automated database.
  • May, in collaboration with clients, prepare initial service plans, including short-term and long-term client goals.
  • May act as client liaison/client advocate with outside organizations regarding such matters as education, healthcare, housing, legal issues, etc.
  • May reach out and market the program to the community in order to recruit clients.
  • Tasks may be modified, expanded and/or assigned over time.

Minimum Educaition/Experience Required:
  • Certified Health Coach.


Other Requirements:

  • Knowledge about, understanding of, and ability to work closely with, persons with HIV/AIDS and related issues.
  • Knowledge about, understanding of, and ability to work closely with, persons with Chronic Illnesses such as Diabetes, Asthma, and related issues.  

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