Behavioral Health Community Health Worker-Stratford

Join a Team That Makes a Difference at Optimus Health Care!
Are you passionate about providing high-quality, patient-centered care? Optimus Health Care—the largest provider of primary health care services in Fairfield County is looking for dedicated professionals to join our team! With multiple locations in Bridgeport, Stratford, and Stamford, our mission is to be a lifelong health care partner, dedicated to achieving optimal wellness for the communities we serve.

The PIC Community Health Worker works closely with medical and behavioral health care teams; fellow Optimus sites CHWs, and social services agencies to provide care coordination, connection to resources and support to improve clients’ health and general well-being. Works in both clinical and community-based settings. Under the supervision of the PIC Program Director, they assess and provide interventions to aid patients to cope with social, emotional, economic, and environmental problems.

• Completes social determinants of health assessments, person-centered recovery action plans oriented to the client’s cultural background including gender identity/sexual orientation. Work with teams to create a trauma informed environment for patients.
• Provides behavioral health resources and interventions when needed (ex: providing breathing exercises for anxiety or sleep hygiene suggestions)
• Schedules and behavioral health screenings, face-to-face whenever possible and clinically appropriate. Supports safe transitions of care for members moving between care settings.
• Works with primary care providers and other CHWs to facilitate referrals to behavioral health department, works with patients to increase compliance with attending intakes, appointments and assists decreasing barriers to participation.
• Assists clients in the clinic setting. Continuously identifies and resolves barriers to meeting goals and complying with the Individual Recovery Plan and reports barriers identified to the PIC Program Manager.
• Documents all client encounters and care coordination efforts made on behalf of clients; maintains comprehensive electronic client files in a consistent and timely fashion.
• Works with PIC team to provide accurate data collection for program reports as well as Optimus team-based care reporting needs.
• Coaches and facilitates communications with clients in effective management of self-care. Assists clients in understanding care plans and instructions. Motivates clients to be active and engaged participants in their health and overall well-being.
• May provide support and advocacy during medical and behavioral health visits or when necessary to guarantee clients' behavioral health and medical needs are being conveyed. Follows up with both clients and providers regarding action plans.
• CHW will be held accountable and assessed by targeted measures from the PIC Grant.
• Facilitates client access to community resources, including housing, food, and clothing assistance, transportation, parenting, providers to teach life skills, vocational, educational resources, and relevant mental health services. Assists clients in utilizing community services, facilitating appointments with community services agencies as well as with completion of applications for programs for which they may be eligible.
• Works collaboratively and effectively within the care team. Establishes positive, supportive relationships with participants and provides feedback to other members of the team. Builds and maintains positive working relationships with the clients, providers, nurse case managers, agency representatives, supervisors, and office staff. Works to reduce cultural and socio-economic barriers between clients and agencies.
• Travels as needed to community locations, various agencies, and other outreach destinations.
• Attend meetings as scheduled or as requested.
• Participate in supervision with supervisor as required.
• Performs other duties as assigned.