Community Health Worker
The NWPHO Embedded Community Health Worker (CHW) is a trusted member of the community who helps patients better access and coordinate their health care.
CHWs are people who come from the communities they serve.
CHWs act as caring neighbors to help patients address the social and medical problems that lead to poor health.
The NWPHO Practice Based Community Health Worker collaborates with the primary care and care coordination team to create and improve patient's ability to navigate the system of care.
The Community Health Worker works directly with the patient and the care team and to ensure patients are receiving the services they need to achieve an optimum quality of life.
The Community Health Worker (CHW) serves as a patient/family advocate, teaching patients/families how to navigate the health and mental health care systems as well community agencies including the social and educational systems to ensure patients are functioning to their full potential by receiving services along the continuum of care.
CHW assists patient navigate the healthcare system.
This will require partnering with patients to help them organize their activities to follow through with essential steps in their health.
This position will involve carrying a defined caseload of patients who are being supported to achieve specific concrete goals.
The CHW caseload predominantly includes patients who are managed independently by the Community Health Worker (i.
e.
CHW as Lead).
A portion of CHW's caseload also patients who are co-managed along with a Nurse Care Manager or Social Worker.
The CHW's expected engagement with a patient is 6 months.
When enrolling a patient, CHW completes an initial assessment and uses critical thinking to identify patient needs and goals.
CHW creates a patient-centered care plan for patient and works with patient to establish goals and address barriers to care.
MAJOR DUTIES AND RESPONSIBILITIES Provide community health work services for patients identified as at risk due to medical or psychosocial challenges.
Attend initial and continuing education training programs including self-directed reading and in-person and online learning.
Assess and address patient needs and triage to Nurse Care Manager and/or Social Work as appropriate Create a patient-centered care plan Content expert on team for social determinants of health related resources and support- including transportation, shelter, food and finances Work with patient and provider to set goals for patient's care.
Assist patients in accessing health insurance including assisting with form completion and encouraging patient follow up.
Meet patients in their homes and perform structured assessments that include goal setting.
Meet patients in the emergency department, primary care clinic or hospital to reinforce and advance patient goals.
Make weekly follow-up calls and regular home visits to patients.
Utilize motivational interviewing techniques to motivate patients to meet their health goals Provide culturally sensitive services to patients from different cultures.
Coordinate with the iCMP Resource Specialists to access resources for identified problems including homelessness, substance abuse and food insecurity after assessment by a licensed social worker clinician.
Assist patients with organizing their records, making follow-up appointments, and filling their prescriptions.
Help patients fill out applications for Medical Assistance and SNAP (Supplemental Nutrition Assistance Program), RAFT (Residential Assistance for Families in Transition), low-income housing applications, emergency financial aid, and other available benefits Follows up with patient/agency to ensure applications are completed and that patient has access to services Provide advocacy, patient education and support in accessing community-based and hospital-based programs.
Refer to internal or external care management services when other issues are identified (i.
e.
food insecurity, domestic violence, etc.
) Work as part of an interdisciplinary team and develop and maintain strong working relationships with the iCMP nurse care coordinator, iCMP behavioral resource specialist, primary care physician and health center behavioral health team.
Document patient encounters in electronic medical record.
Qualifications:
Relevant experience in the community or Associates Degree, Bachelor's Degree preferred.
1-2 years' prior experience working with patients and families dealing with complex medical and psychiatric/behavioral problems; ability to help patients and families/caregivers understand and access the resources required to support care, ideally with experience in private/public educational systems, community mental and behavioral health centering on holistic patient and family care.
Bilingual preferred.
Experience as a community health worker, peer specialist, peer advocate, or in a similar role preferred.
Experience working with a variety of community agencies and resources preferred.
Ability to work effectively in a complex fast paced medical environment and multiple practice locations.
SKILLS/ABILITIES/COMPETENCIES REQUIRED Local community resident with good knowledge of the resources of the community.
Prior experience as a community health worker, health coach or outreach worker desired; health care experience a plus but not required.
Demonstrated commitment to patient advocacy.
Solid knowledge of the Core Competencies for CHWs (as identified by Massachusetts, Department of Public Health) Excellent organizational skills with an ability to set priorities.
Excellent oral and written communication skills.
Strong critical thinking and problem-solving skills.
Comfort in working with health care computer systems.
Excellent interpersonal skills and ability to work effectively with physicians and their staff in a physician practice setting.
Flexibility in schedule, occasionally adjusting to accommodate patient and provider needs.
Ability to adapt to practice and program needs.
Ability to work independently to manage panel of patients Recommended Skills Adaptability Assessments Behavioral Medicine Care Coordination Communication Community Health Estimated Salary: $20 to $28 per hour based on qualifications.
CHWs are people who come from the communities they serve.
CHWs act as caring neighbors to help patients address the social and medical problems that lead to poor health.
The NWPHO Practice Based Community Health Worker collaborates with the primary care and care coordination team to create and improve patient's ability to navigate the system of care.
The Community Health Worker works directly with the patient and the care team and to ensure patients are receiving the services they need to achieve an optimum quality of life.
The Community Health Worker (CHW) serves as a patient/family advocate, teaching patients/families how to navigate the health and mental health care systems as well community agencies including the social and educational systems to ensure patients are functioning to their full potential by receiving services along the continuum of care.
CHW assists patient navigate the healthcare system.
This will require partnering with patients to help them organize their activities to follow through with essential steps in their health.
This position will involve carrying a defined caseload of patients who are being supported to achieve specific concrete goals.
The CHW caseload predominantly includes patients who are managed independently by the Community Health Worker (i.
e.
CHW as Lead).
A portion of CHW's caseload also patients who are co-managed along with a Nurse Care Manager or Social Worker.
The CHW's expected engagement with a patient is 6 months.
When enrolling a patient, CHW completes an initial assessment and uses critical thinking to identify patient needs and goals.
CHW creates a patient-centered care plan for patient and works with patient to establish goals and address barriers to care.
MAJOR DUTIES AND RESPONSIBILITIES Provide community health work services for patients identified as at risk due to medical or psychosocial challenges.
Attend initial and continuing education training programs including self-directed reading and in-person and online learning.
Assess and address patient needs and triage to Nurse Care Manager and/or Social Work as appropriate Create a patient-centered care plan Content expert on team for social determinants of health related resources and support- including transportation, shelter, food and finances Work with patient and provider to set goals for patient's care.
Assist patients in accessing health insurance including assisting with form completion and encouraging patient follow up.
Meet patients in their homes and perform structured assessments that include goal setting.
Meet patients in the emergency department, primary care clinic or hospital to reinforce and advance patient goals.
Make weekly follow-up calls and regular home visits to patients.
Utilize motivational interviewing techniques to motivate patients to meet their health goals Provide culturally sensitive services to patients from different cultures.
Coordinate with the iCMP Resource Specialists to access resources for identified problems including homelessness, substance abuse and food insecurity after assessment by a licensed social worker clinician.
Assist patients with organizing their records, making follow-up appointments, and filling their prescriptions.
Help patients fill out applications for Medical Assistance and SNAP (Supplemental Nutrition Assistance Program), RAFT (Residential Assistance for Families in Transition), low-income housing applications, emergency financial aid, and other available benefits Follows up with patient/agency to ensure applications are completed and that patient has access to services Provide advocacy, patient education and support in accessing community-based and hospital-based programs.
Refer to internal or external care management services when other issues are identified (i.
e.
food insecurity, domestic violence, etc.
) Work as part of an interdisciplinary team and develop and maintain strong working relationships with the iCMP nurse care coordinator, iCMP behavioral resource specialist, primary care physician and health center behavioral health team.
Document patient encounters in electronic medical record.
Qualifications:
Relevant experience in the community or Associates Degree, Bachelor's Degree preferred.
1-2 years' prior experience working with patients and families dealing with complex medical and psychiatric/behavioral problems; ability to help patients and families/caregivers understand and access the resources required to support care, ideally with experience in private/public educational systems, community mental and behavioral health centering on holistic patient and family care.
Bilingual preferred.
Experience as a community health worker, peer specialist, peer advocate, or in a similar role preferred.
Experience working with a variety of community agencies and resources preferred.
Ability to work effectively in a complex fast paced medical environment and multiple practice locations.
SKILLS/ABILITIES/COMPETENCIES REQUIRED Local community resident with good knowledge of the resources of the community.
Prior experience as a community health worker, health coach or outreach worker desired; health care experience a plus but not required.
Demonstrated commitment to patient advocacy.
Solid knowledge of the Core Competencies for CHWs (as identified by Massachusetts, Department of Public Health) Excellent organizational skills with an ability to set priorities.
Excellent oral and written communication skills.
Strong critical thinking and problem-solving skills.
Comfort in working with health care computer systems.
Excellent interpersonal skills and ability to work effectively with physicians and their staff in a physician practice setting.
Flexibility in schedule, occasionally adjusting to accommodate patient and provider needs.
Ability to adapt to practice and program needs.
Ability to work independently to manage panel of patients Recommended Skills Adaptability Assessments Behavioral Medicine Care Coordination Communication Community Health Estimated Salary: $20 to $28 per hour based on qualifications.
|
|
 | |
