Community Health Worker-Street Medicine

Brief Description

The Community Health Worker (CHW) & Medical Assistant*-Street Medicine Program contributes to meeting the comprehensive needs of the patient that include social determinants of health and direct medical services. Under the Primary Care Medical Home (PCMH) model, CHWs contribute to patient recruitment, education, navigation, social support, medical follow-up needs, care coordination and integration. Chronic disease management and risk factor reduction are often the focus of these efforts for the CHW with proven interventions on chronic disease prevention and control.

* Highly preferred and will train on-the-job.

• Team-Based Work Environment
• 90 Day Introductory Period
• Awesome benefits
• Medical, Dental, Vision, life insurance, short & long-term disability, and 403(b) Retirement Plan, FSA, and other voluntary benefits
• Vacation, Holiday and Sick Benefits

Provide patient services in the health center and outside in the community for patient recruitment.

Patient services are provided for existing patients and patient recruiting is conducted within targeted communities (which includes all census tracts on Maui island, with the exception of Hana) on a rotational basis, to perform:

• Care coordination and integration, to include working with patient, partners, families and caregivers.
• Resource identification.
• Goal setting and assistance with self-monitoring.
• Culturally and age appropriate education to include instructional materials, with multiple language options, health screens, and clarification of care plans in compliance with clinical protocols.
• Patient recruitment includes contacting assigned individuals who have yet to establish care, educating them about the range of services available to them at the health center, and expansion of translation and/or interpretation services available to patient.

Community Health Workers provide, deliver, and/or manage needed culturally and age appropriate services such as:

• Education and communication materials, educational tools, multimodality approaches to care in multiple languages.
• Implement and monitor care management plans.
• Assistance with appointment scheduling.
• Psychosocial support.
• Eligibility referrals.
• Translation and/or interpretation services as qualified.
• Coordination of transport
• A Patient Assistance Program (PAP) to provide financial assistance to access complementary and alternative care options as well as healthy foods.

• Provides medical assistance to the Street Medicine Provider
• Verify patient identity, including at least two identifiers: full name and date of birth.
• Take and record vital signs, patient medical history, medication list, pharmacy information, and current health concerns
• Per provider instructions, screen for SDOH, alcohol, PHQ2, GAD 2, smoking, substances, safety, and other high needs.
• Obtain consent release to obtain medical records, if provider requests.
• Identify patient’s special needs, such as translation and transportation, to collaborate/coordinate with CHW services.
• Collects and documents visit information in the EMR, including the purpose of the visit, transition of care if applicable, phone notes, scheduling, etc.
• Confers with and reports in SBAR format to the Street Medicine Provider.
• Facilitates QUEST application process or applicable sliding fee information if patient is not eligible for QUEST.
• Per provider instructions, administers medications and injections/immunizations.
• Per provider instructions, discharges patient with AVS (After Visit Summary) and verifies understanding as needed.
• Assists Street Medicine Provider with EMR, patient-related paperwork, referrals, prior authorizations (PAs).
• Checks and refills Street Medicine inventory prior to departing health center; checks equipment for functionality and reports needed repairs; sterilizes equipment and instruments.
• Meets on regular frequency with Clinical Operations Manager and implements instructions.
• Participates in self‑education and assigned education as required to maintain patient care competencies.
• Works with…