Position Summary: The Community Health Worker (CHW) is an integral member of an interdisciplinary healthcare team. The CHW will work closely with patients, the health care team, social services providers, and community partners to effectively manage the care of patients. Organizes and facilitates care activities and promotes self-management by advocating for, empowering, and educating the patient. Ensures safe, appropriate, non-duplicative, and effective integrated care. Must deliver healthcare-related services that are of quality, efficient and cost-effective, and in a professional manner. Provided services must be patient-centered and promote self-care and self-management by the patient.
Essential Duties and Responsibilities include the following. Other duties may be assigned:
· Assist individuals and communities to adopt healthy behaviors.
· Conduct outreach to implement programs in the community that promote, maintain, and improve individual and community health.
· Responsible for building and maintaining an active patient caseload necessary to meet productivity requirements.
· Assist in developing processes and procedures related to CHW roles and translate materials.
· Participate in new program initiatives related to CHW roles, and advocate for patients and community health needs to ensure the appropriateness of initiatives.
· Conduct patient outreach and engagement activities patients, including face-to-face, mail, electronic, and telephone contact.
· Conduct outreach and engagement activities that support patient continuity of care, including re-engaging patients in care if they miss appointments and/or do not follow up on treatment.
· Assist patients in completing patient consent and other clinic or program-related forms.
· Conduct initial and periodic needs assessments using tools to collect social determinants of health data, including assessing barriers and assets (e.g., transportation, community barriers, social supports); patient preferences; and language, literacy, and cultural preferences.
· Support the development and execution of patient care plans, including assisting patients in understanding care plans and instructions and tailoring communications to appropriate health literacy levels.
· Conduct home visits and accompany patients to clinic visits per protocol or as determined in consultation with the supervisor.
· Promote patient treatment adherence through assessing patient readiness to make changes; assisting patients in making changes to daily routines; identifying barriers; and assisting patients with developing strategies to address barriers.
· Provide social support and informal counseling, behavioral change support, and assistance with goal setting and action planning.
· Assist patients with navigating health care and social service systems, including arranging for transportation and scheduling and accompanying patients to appointments as determined in consultation with the supervisor.
· Assist care managers in monitoring and evaluating patients’ needs, including for prevention, wellness, medical, specialist, and behavioral health treatment; care transitions; and social and community service needs.
· Identify available community-based resources, and actively manage appropriate referrals, access, engagement, follow-up, and coordination of services to patient supports and resources, including resources related to housing; prevention of mental illness and substance use disorders; smoking cessation; diabetes; asthma; hypertension; self-help/recovery resources; and other services based on individual needs and preferences.
· Document all efforts to address SDOH issues in electronic medical records.
· Provide support and education for chronic disease self-management to patients and their families.
· Coordinate access to the basic determinants of health (e.g., food, clothing, shelter, income, utilities).
· Use health information technology to link to services and resources and communicate among team members, providers, patients, and their families/caregivers.
· Provide information on patients to the healthcare team as appropriate for a greater understanding of the patient.
· Electronically document activities and patient information and interventions in patients’ electronic health records.
- Participate in events and projects with collaborating agencies to exchange information and remain current with developments in the field.
· Promote and educate patients on patient portal access and other CHASS electronic applications.
· Collect and report on data for program evaluation and assist in the analysis and dissemination of research findings.
· Manually and/or electronically document activities and patient information and interventions in patient-tracking systems, care management software programs, and other program systems.
· Will be assigned to different CHASS facilities on a rotational basis.
· Other duties as assigned.
Special requirements, qualifications, Licenses, or certifications:
· Experience working as a Community Health Worker with a target population.
· Must be fully bilingual in Spanish and English.
· Requires to travel between CHASS Facilities as needed.
· The position requires independent travel to participant homes, and working evenings and weekends as needed to accommodate patient needs and preferences.
· Must have a valid Michigan driver’s license and access to an insured automobile that lists the employee on the insurance policy.
Minimum of high school diploma or GED.
Job Type: Full-time
Pay: $16.89 - $18.39 per hour
Benefits:
- 401(k)
- Dental insurance
- Health insurance
- Paid time off
- Tuition reimbursement
- Vision insurance
Schedule:
- 8 hour shift
- Day shift
- Monday to Friday
Language:
Work Location: In person