Community Health Worker

The Community Health Worker (CHW) is a non-clinical member of CHJC’s MHOTRS treatment team who works directly with individuals and families to reduce barriers to accessing healthcare, behavioral health treatment, and community-based services.

The CHW serves as a link between individuals, the treatment team, healthcare providers, and community resources. Through outreach, education, advocacy, resource navigation, and practical support, the CHW assists individuals in identifying and addressing health-related social needs that may impact their ability to access or participate in care.

CHW services are intended to provide targeted support and navigation and do not replace comprehensive or ongoing care management services. Individuals who are currently enrolled in Medicaid Health Home Care Management will be referred to and supported through their assigned Care Manager for needs that fall within the scope of Health Home Care Management.

When an individual receiving CHW services demonstrates a need for ongoing, comprehensive care management, the CHW will assist the individual with referral and linkage to an appropriate care management program when eligible.

The CHW works collaboratively with clinicians, medical providers, nursing, clinic operations, Care Management, and community partners while maintaining clear role boundaries and avoiding duplication of services. The CHW does not provide clinical assessment, psychotherapy, medication management, or other services requiring professional licensure.

1. Conduct outreach and engagement with individuals referred for Community Health Worker services.

2. Identify and assist individuals with health-related social needs and barriers affecting access to healthcare and behavioral health services, including transportation, food, housing, insurance/benefits, and access to community resources.

3. Assist individuals in navigating healthcare and social-service systems, including establishing or connecting with primary care, specialty care, behavioral health services, preventive healthcare, and other appropriate community services.

4. Provide referrals, warm handoffs, and follow-up to help individuals successfully connect with recommended healthcare and community resources.

5. Assist individuals with transportation coordination and other practical barriers that interfere with their ability to access or participate in care.

6. Assist individuals with insurance, benefits, community-resource applications, and other service-navigation needs within the scope of the CHW role.

7. Provide health education and information in an accessible and culturally responsive manner and assist individuals in understanding how to access appropriate healthcare resources.

8. Advocate for individuals and support effective communication between individuals, families, healthcare providers, behavioral health providers, and community organizations.

9. Collaborate with the MHOTRS treatment team regarding individuals receiving CHW services and communicate relevant updates regarding referrals, identified barriers, interventions, and outcomes.

10. Support patient engagement and re-engagement by addressing identified non-clinical barriers that may interfere with participation in behavioral health treatment.

11. Support transitions of care by assisting individuals with access to recommended follow-up services and community resources following hospitalization, emergency department utilization, or other transitions in care.

12. Identify individuals whose needs may exceed the scope of targeted Community Health Worker services and may benefit from ongoing, comprehensive care management. Assist eligible individuals with referral and linkage to Medicaid Health Home Care Management or other appropriate care management services.

13. Verify and coordinate with the treatment team regarding existing care management involvement when appropriate. Individuals actively enrolled in Medicaid Health Home Care Management will be directed to their assigned Care Manager for services within the scope of Health Home Care Management to prevent duplication of services.

14. Facilitate warm handoffs to Care Management when an individual is referred for ongoing care management services and communicate relevant information necessary to support continuity of care.

15. Participate in treatment team meetings, case reviews, and other interdisciplinary meetings as appropriate to the individual's needs and the CHW's…