Principal illness navigation - peer support by certified or trained auxiliary personnel under the direction of a physician or other practitioner, including a certified peer specialist; 60 minutes per calendar month, in the following activities:
- person-centered interview, performed to better understand the individual context of the serious, high-risk condition.
- conducting a person-centered interview to understand the patient's life story, strengths, needs, goals, preferences, and desired outcomes, including understanding cultural and linguistic factors, and including unmet sdoh needs (that are not billed separately).
- facilitating patient-driven goal setting and establishing an action plan.
- providing tailored support as needed to accomplish the person-centered goals in the practitioner's treatment plan. identifying or referring patient (and caregiver or family, if applicable) to appropriate supportive services. practitioner, home, and community-based care communication.
- assist the patient in communicating with their practitioners, home-, and community-based service providers, hospitals, and skilled nursing facilities (or other health care facilities) regarding the patient's psychosocial strengths and needs, goals, preferences, and desired outcomes, including cultural and linguistic factors.
- facilitating access to community-based social services (e.g., housing, utilities, transportation, food assistance) as needed to address sdoh need(s).
- health education. helping the patient contextualize health education provided by the patient's treatment team with the patient's individual needs, goals, preferences, and sdoh need(s), and educating the patient (and caregiver if applicable) on how to best participate in medical decision-making. building patient self-advocacy skills, so that the patient can interact with members of the health care team and related community-based services (as needed), in ways that are more likely to promote personalized and effective treatment of their condition.
- developing and proposing strategies to help meet person-centered treatment goals and supporting the patient in using chosen strategies to reach person-centered treatment goals.
- facilitating and providing social and emotional support to help the patient cope with the condition, sdoh need(s), and adjust daily routines to better meet person-centered diagnosis and treatment goals. leverage knowledge of the serious, high-risk condition and/or lived experience when applicable to provide support, mentorship, or inspiration to meet treatment goals