LPN​/CHW

SUMMARY

This role is pivotal in bridging clinical care and community resources, ensuring patients receive comprehensive support across all counties served by Axess Family Services.

LPN’s play a critical role in the delivery of quality medical care within the context of a federally qualified community health center. The LPN participates in the multi-disciplinary process of providing care and treatment to patients and provides clinical support and technical assistance to the professional medical and other staff. LPN’s are responsible for functioning within the scope of practice for their licensure or certification.

They must be able to manage a demanding workload with accuracy. Position requires excellent customer service skills with patients and their families, other staff, providers, vendors, and the public.

The Community Health Worker (CHW) provides community support services by partnering with other community agencies to help at risk / high risk individuals and their families navigate complex social service and health care systems to services to promote healthy behaviors and manage conditions that affect their health and social well-being. This culturally and geographically connected individual serves as a link between underserved communities and existing community resources.

Through home visiting, these individuals assists clients in overcoming barriers to health, social services, education, and employment by performing the following duties.

Director of Community Impact or Designee

• Perform LPN duties in accordance with state regulations and organizational standards.
• Assist with pre-visit planning to optimize patient care and provider efficiency.
• Assist with Clinic wide PREVISIT planning to address SDOH concerns
• Assist with Quality Metrics by chart review
• Coordinate scheduling on Physician scheduling availability to optimize patient success
• Connects the client to Medicaid and a medical home for preventive services within 14 days of program enrollment.
• Educates enrolled clients regarding topics such as hygiene, community groups and stress management.
• Attends training and monthly meetings and submit documentation of same to supervisor.
• Secures information such as medical, psychological, and social factors contributing to client's situation, and forwards information to clinical professionals for evaluation.
• Helps clients and families through individual or group conferences to understand, accept, and follow medical recommendations.
• Reviews care plan developed by clinical professionals and performs appropriate follow-up activities as directed.

• Connects the client to Medicaid and a medical home for preventive services within 14 days of program enrollment
• Works with the clients to connect them to community social services to remove barriers to care (e.g. transportation, housing, mental health counseling, etc.).
• Interviews clients with problems such as personal and family adjustments, health, finances, employment, food, clothing, housing, utilities, and physical and mental impairments; completes appropriate checklist; and brings information back to agency clinical professionals to determine nature and degree of problem.
• Enter information from home visits into database in an accurate and timely manner.
• Accesses and records client’s and community’s resource information in required system.
• Advocates for client and acts as a liaison between client and other service providers.
• Counsels client individually, in family or other small groups, regarding plans for meeting needs and aids client to mobilize inner capacities and environmental resources to improve social functioning.
• Secures supplementary information such as employment or medical records or school reports as directed.
• Determines client's eligibility for services such as financial assistance, insurance and other programs in place to assist individuals and refers clients to community resources and other agencies to meet identified needs.

The Duties and Responsibilities above represent the most significant duties of this position, but do not exclude other assignments that would be within the qualification and…