Community Health Worker, IBH

Job Summary

The Integrated Behavioral Health Community Health Worker (IBH CHW) is a critical member of the integrated health care team. Under the supervision of a licensed Behavioral Health Clinician (BHC), the IBH CHW works within an interdisciplinary team alongside primary care providers (PCPs) and BHCs. The IBH CHW is distinct from a Case Manager, Care Coordinator, or Resource Specialist in that the role is grounded in shared characteristics of the population served, e.g., language, race/ethnicity, experiences, and the care is often provided at the time of need when patients present to their PCP in the primary care clinic.

In this role, the IBH CHW will engage children, adolescents, adults, and families, and provide health education and care coordination to address care gaps and medical and behavioral health care needs.

The IBH CHW will work with patients with behavioral and developmental health needs to improve overall health outcomes. They will assess strengths, needs, and barriers across all aspects of accessing care. The IBH CHW may serve as a point of contact for caregiver(s), providing mentorship and supporting access to care at various points of the process, as well as connecting individuals and families facing economic and social challenges to community resources.

• Engage and maintain trusting relationships with patients and caregivers, including outreach to individuals and families lost to care via face-to-face, mail, electronic, and telephone contact; and community outreach to promote public health messages.
• Monitor and proactively evaluate emerging needs for prevention, wellness, medical, and behavioral health care in collaboration with the PCP, BHC, and other members of the care team.
• Assist in the development and implementation of attainable goal setting, goal and action planning, promote adherence to care plans, and identify and overcome any potential barriers.
• Partner with patients and caregivers to support care plans and ensure continuity of care.
• Encourage consumers to attain the highest possible levels of independence, accepting the values and lifestyles of patients.
• Use a flexible approach with a diverse population.
• Utilize evidence-based engagement strategies, such as Motivational Interviewing (MI) and Problem-Solving Techniques.
• Assess symptoms and risk level, and provide appropriate crisis interventions and risk management as needed.
• Provide care in a calm and professional manner during crisis or emergency situations.
• Assess consumers' unmet needs (psychological, physical, housing, and psychiatric).

• Provide health education and information to improve patient and/or caregivers’ knowledge and understanding of issues such as typical child development, chronic diseases, mental and behavioral health issues; including symptoms, diagnosis, management, and available resources and services to promote informed decisions making related to care.
• Provide education and support to increase patient and caregiver self-management skills to anticipate and address barriers accessing services and treatment. For example, transportation, gathering supporting documents, advocating, and self-assessment of issues such as symptoms escalating, need for emergency services, etc.
• Provide education on screening and treatment for emotional, behavioral, and developmental needs.
• Provide education and coaching to address mental and behavioral health concerns, including substance use.

• Promote continuity of care through ongoing collaboration with patients, caregivers, PCPs, BHCs, and other care team members.
• Support referral processes and assist individuals and families in accessing and connecting to appropriate services for behavioral and developmental health needs.
• Identify and build relationships with community resources, such as community-based mental health providers, Early Intervention, schools, and other local service providers to increase capacity for collaboration.
• Assist individuals and families in addressing health-related social needs, such as health insurance, food, clothing, housing, entitlement and government assistance programs, and other appropriate community resources and services.
• Promote completion of care plan goals by assessing readiness for change, identifying and addressing barriers, and assisting individuals and families in making changes to daily routines.

• Complete recordkeeping in accordance with Health Information Services (HIS) and other Center requirements within required time frames and abide by hospital confidentiality policy.
• Complete progress notes with appropriate format.
• Monitor confidentiality in accordance with agency policy and legal requirements.

• Follow required office procedures in a cooperative manner.
• Ability to work collaboratively within an interdisciplinary care team and independently to ensure quality/timely care for patients' medical and behavioral health needs.
• Ability to adhere to high…