Community Health Worker

Job Summary

The Community Health Worker Apprentice is a member of the community health team; an interdisciplinary team comprised of Community Health Workers, Behavioral Health Clinicians and practice-based Nurse Care Managers. Works closely with the core team members to support patients who are dealing with complex medical, behavioral health and/or substance issues as well as social determinants of health and require a more intensive home and community-based intervention.

The Community Health Worker plays a critical role in assessing patient needs, offering community resources and referrals, providing navigation, support, care coordination, and ongoing case management to meet those needs. Visits patients in their homes and in the communities in which they live, providing culturally sensitive approaches to health information to improve health literacy. The Community Health Worker facilitates the patient’s decision-making and self management to help patients engage in their overall health and achieve their health goals.

This individual will be responsible for tracking patient related activities, monitoring and documenting progress. Works collaboratively with the primary care team to promote patient-centered care and actively participates in multidisciplinary patient-centered team meetings. The Community Health Worker has frequent contact with many community agencies on behalf of the patients served, networking and collaborating on resource identification to improve the overall health of the population.

• Initiates outreach and successfully engages with patients to enroll in the community health team program, scheduling appointments and providing follow-up contact within designated time frames.
• Completes initial intake, including a comprehensive assessment of social needs, functional assessment of the patient in the home setting, and condition of the home if needed within designated time frames.
• Builds trusting relationship and serves as an advocate and mentor with the goal of empowering the patient to become more independent and self-sufficient.
• Collaborates with nurse care managers, physicians, other care team members (Medical Assistants, Nurses, etc.), hospitals, partner agencies, members of the CHT in the patient’s network of care to improve patient care.
• Obtains releases, gathers PHI from outside providers involved in patient care as needed and processes documents according to program requirements.
• Accompanies patients to doctor’s appointments, assists with food planning/shopping, picking up prescriptions at the pharmacy, completing forms for benefit applications, and assists with other tasks as needed.
• Educates patients on appropriate Urgent Visit and ED use.
• Utilizes a multi-disciplinary team approach to address opportunities to plan and coordinate care.
• Utilizes Motivational Interviewing skills and other patient engagement techniques with patients and caregivers.
• Assists in the development of a patient care plan to include actions designed to improve the patient’s health status, and removes the barriers that are preventing them from gaining access to high quality and timely primary/specialist care.
• Leverages EMR/chronic disease registry reporting to prioritize patient follow-up.
• Identifies and utilizes culturally sensitive approaches and community resources.
• Documents activities and communications in the patient registry as defined by program requirements.
• Provides training to other team or practice staff as needed.
• Acts as liaison to health plans, hospital, long-term care, BH specialists and home health representatives.
• Attends required training and collaborative sessions as scheduled.
• Performs other related duties as requested and serves on various system wide committees

High school graduate or GED required. Must have resided in the Greater Olneyville community (02909 zip code) for two years and have knowledge of community resources. Valid driver’s license with reliable transportation and proof of minimum auto insurance required. Bilingual Spanish required. Knowledge of Medicaid and Managed care preferred. Effective communication skills and ability to engage…