Community Health Worker

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FT Professional Lafayette, IN, US

2 days ago Requisition

The Community Health Worker (CHW) provides personalized support to patients and families, helping them navigate healthcare and community resources. The CHW works closely with healthcare providers and community partners to address social determinants of health, connect patients to needed resources, and support continuity and transitions of care. Under the GROW Chronic Disease Support and Prevention initiative, the CHW also provides community- and home-based outreach and support for high-risk individuals with diabetes, hypertension, cardiovascular disease, COPD, and other chronic conditions across Benton, White, Carroll, Clinton, Warren, Fountain, Montgomery, and Boone Counties.

The role is designed to reduce barriers to care, strengthen chronic disease self-management, improve patient engagement, and connect individuals identified in the field to timely clinical and supportive services.

• Conduct comprehensive assessments and standardized social needs screenings to identify social determinants of health (SDoH), barriers to chronic disease management, and needed community or healthcare resources.
• Provide individualized care coordination and guidance through healthcare processes, including appointments, referrals, follow-up care, and connection to appropriate clinical and supportive services.
• Provide approved chronic disease education and self-management support for patients with diabetes, hypertension, cardiovascular disease, COPD, and other chronic conditions, consistent with organizational education pathways and the CHW scope of practice.
• Use motivational interviewing, health-literacy principles, and patient-centered communication to support engagement, self-management goals, and understanding of the established care plan.
• Identify and address barriers such as missed appointments, transportation challenges, food insecurity, housing needs, financial hardship, medication-access or medication-adherence concerns, language or health-literacy barriers, and other unmet social needs.
• Provide transportation assistance and navigation consistent with organizational policy and approved program workflows, including helping patients identify and access appropriate transportation resources.
• Provide appointment support, reminders, scheduling assistance, referral navigation, and follow-up to help patients remain connected to primary, specialty, and other needed care.
• Use closed-loop referral practices by tracking referrals and resource connections, following up on outcomes, and escalating unresolved barriers to the appropriate care team member.
• Engage in proactive outreach to high-risk patients, including individuals with uncontrolled chronic conditions, gaps in care, missed appointments, difficulty managing medications, worsening symptoms, or other barriers identified through approved referral and outreach workflows.
• Conduct approved home visits, community outreach, facility visits, and other field-based activities throughout the assigned service area to improve access to care and support chronic disease management.
• During field encounters, identify patient concerns and barriers, reinforce approved education and the established care plan, and promptly communicate clinical concerns to the designated clinical support team.
• Coordinate closely with the GROW clinical support structure, including the designated Nurse Practitioner, Licensed Practical Nurse, Medical Assistant, providers, nursing leadership, and other care team members to facilitate timely response to needs identified in…