Community Health Worker

Summary:

The CSP/HRSN Community Health Worker (CHW) provides intensive case management services to individuals who have a Health Needs Based criteria (HNBC) and risk factor as defined by Mass Health for CSP and HRSN Supplemental Housing Services. These services are designed to be maximally flexible in supporting individuals to implement their clinical treatment plans and attain the skills and resources needed to maintain community tenure.

Job Duties and Responsibilities:

The essential job duties/responsibilities of the position include but are not limited to the information listed below:

• Coordinates the completion of the Intake, Assessment, and Treatment Plan.
• Conducts initial and ongoing risk assessment, designs personal crisis management plans, relapse prevention and harm reduction strategies with team clinician.
• Drives referrals to any community or social services that align with a member’s needs and goals.
• Collaborates closely with PCP and other providers, including but not limited to community resources, to assure appropriate referrals based on level of care needed which optimize outcomes and minimize risk.
• Assists members in improving daily living skills so members are able to perform them independently or access services to support them in doing so.
• Provides temporary assistance with transportation to essential medical and behavioral health appointments while transitioning to community-based transportation resources (e.g., public transportation resources, PT-1, etc.).
• Accompanies members to essential health care appointments, as needed.
• Assists with obtaining benefits, housing, and health care.
• Collaborates with Emergency Services Programs/Mobile Crisis Intervention (ESP/MCIs) and/or outpatient providers; including working with ESP/MCIs to develop, revise and/or utilize crisis prevention plans and/or safety plans.
• Fosters empowerment, recovery, and wellness, including forming connections to recovery-oriented peer support and/or self-help support and services.
• Manages all care transitions through collaboration with members, community provider staff, ICT, and hospital staff to ensure a safe discharge plan and a well-coordinated implementation of that plan.
• Completes required Service Notes and case documentation in electronic health record to ensure accurate and timely billing of services.
• Participates in routine multidisciplinary team meetings.
• Completes all assigned courses on Vinfen Learning Management System and other training/in-service/workshops in best practices as assigned by supervisor.
• Provides Pre-Tenancy Supports, including helping members identify housing preferences, assistance with budgeting or referral to housing financial aid programs, ensuring completion of subsidized housing applications, support with required follow up to applications and connection to community resources to access safe temporary housing.
• Provides Tenancy Transition Services to individuals moving to new home environments to include lease negotiations, necessary accommodations, budgeting and rental payment plans, access to needed furniture, equipment and in home health services.
• Provides Tenancy Sustaining supports to individuals with at risk tenancies include negotiating with landlords regarding accommodations, connecting to tenancy sustaining benefit programs, providing education regarding lease compliance, and connecting to legal, financial and other resources required for successful community living.
• Performs outreach to assigned members to complete housing assessments and design targeted housing plans.
• Completes in home assessment to determine remediation needs as needed and arranges for reputable contractor to address identified remediation need(s).
• Identifies the need for and…