Community Health Worker

POSITION SUMMARY

A Community Health Worker (CHW) is a trusted member of the community who helps high risk patients improve health and wellness along a continuum, through integrating and connecting hospital, home-based, and community-based services. CHWs are responsible for providing advocacy and case management services; developing an interdisciplinary care plan based on identified patient needs; facilitating access to social service resources and other internal and external resources;

monitoring the patient’s progress; and problem-solving with patients and families to both accelerate and enhance access to concrete supports.

CHWs provide in-home or community-based one-on-one, family, and/or interdisciplinary group support to high risk care patients and collaborates with the ECPS team, primary care team, community based care managers and other members of the care team to conduct needs assessments to identify and respond to barriers to the patient’s health and wellness.

• Initiates face to face contact with eligible patients to describe role, explain participation benefits and begin screening process.
• Schedules and completes initial hospital, clinic, or community-based (homes, assisted livings, shelters, housing agencies, substance use treatment programs, etc.) visit screening, care plan, and follow up visits and phone calls for enrolled patients within specified time frames.
• Teaches key educational messages using a variety of culturally, linguistically and educationally appropriate strategies, in a variety of settings.
• Clearly documents all activities in the patient’s electronic health record and care management system.
• Participates with other staff in activities that include community outreach and education, presentations to community organizations, development of materials, and phone calls.
• Works with patients and clinicians to set goals for patient’s care and provides guidance for patients to achieve those goals.
• Reinforces educational messages regarding disease self management by linking clients with supportive community services and programs.
• Presents patients at clinical team huddles succinctly and logically.
• Consults with primary clinical staff, behavioral health teams and / or PCP regarding complex patient situations, demonstrating an understanding of how to solicit and incorporate provider feedback in order to continuously develop the most optimal plan for care.
• Demonstrates the ability to function within an inter-disciplinary team (nurse care coordinators, social workers, behavioral health clinicians, physicians, nurse practitioners, resource specialists, clinical support staff, etc.), connecting the patient with resources as needed.
• Records and monitors the participants’ progress toward goals within specific time frames.
• Documents assessments and key patient updates in Epic system; documents relevant day-to-day activities and patient data.
• Prepares reports and documents as needed or requested.
• Assists patients with organizing their records, making follow-up appointments, attending follow-up appointments, and filling their prescriptions. Helps patients fill out applications, such as for Medical Assistance, Housing, and SNAP (Supplemental Nutrition Assistance Program).
• Provides advocacy, patient education and successful warm hand offs in accessing community-based and hospital-based programs.
• Assists patients in addressing and overcoming barriers with a range of concrete supports, including but not limited to: homecare services, healthcare support services, behavioral health, financial assistance, child-care and caregiver support, housing, support with utility bills, food, financial entitlements, clothing, transportation, food pantries, violence prevention, social isolation and any other appropriate community resources.
• Coordinates with community-based long-term services and supports.
• Provide intensive home and community-based outreach, motivational interviewing and goal setting, resource connection and accompaniment to medical appointments as needed to help patients appropriately…