The Community Health Worker (CHW) will be responsible for assisting patients and their families to navigate and access community services, other resources, and adopt healthy behaviors. The CHW supports providers and the Care Coordination efforts through an integrated approach to care management and community outreach. As a priority, activities will promote, maintain, and improve the health of patients and their family. The CHW will provide social support and informal counseling, advocate for individuals and community health needs. In addition, the CHW will have the following responsibilities:
Assist patients with a need for education related to their diabetes (nutrition, physical activity, and/or weight management) as well as assistance with understanding coverage options and help to enroll in patient assistance programs. For patients requiring more intensive services, the Community Health Worker will complete home visits in attempts to bridge the gap in knowledge related to diabetes.
Will participate in outreach events in order to recruit patients for the program.
Chronic Disease Quality Improvement Initiative
Assist patients with uncontrolled diabetes, hypertension and/or coronary artery disease, to assist patients in meeting basic healthcare needs. Assist with appointment reminders and serve as a link between the community and healthcare systems. Gauge patient’s knowledge and understanding regarding medications and chronic disease by discussing current lifestyle behaviors and provide information regarding lifestyle modifications. Conduct follow-up calls and/or meetings to evaluate progress, compliance, problem-solving and self-management.
Knowledge, Skills, and Abilities
- Knowledge about community resources appropriate to needs of patients/families.
- Ability to provide consistent communication to the Care Coordination Manager to evaluate patient/family status, ensuring that provided information, and reports clearly describe progress.
- Skills in written and oral English
- Ability to work in a multi-cultural setting.
- Knowledge of basic medical terminology.
- Knowledge of basic computer skills.
- Ability to initiate and maintain a positive working relationship with CFHC staff and other organizations.
- Understanding of the community served – community connectedness.
- Ability to communicate efficiently, including verbal and listening skills.
- The ability and willingness to provide emotional support, encouragement and motivation to patients and families.
- Skills in basic reporting and tracking of patient services through manual and electronic processes.
The ability to travel for job duties and trainings.
- High School Diploma or its equivalent.
- Successful completion of a Community Health Worker formal training program such as from a college or other education institution is preferred.
- Experience working in a multi-cultural setting.
- Basic computer skills
- Establishes a trusting relationship with patients and their families, while providing general support and encouragement.
- Provides ongoing follow-up visits utilizing basic motivational interviewing and goal setting with patients and families.
- Conducts intake interviews with patients and promotes referral for services into Coastal Family Health Center, its programs, and other available community resources as appropriate.
- Follows up with patients through phone calls, home visits and community events (health fairs, community forums, advocacy meeting and workshops).
- Assists patients with completing applications and registration forms for various patient services.
- Conducts eligibility determination, enrollment and follow-up with uninsured patients.
- Assists patients in setting personal healthcare goals.
- Assists patients in connecting with transportation resources.
- Exhibits excellent working relations with patients, visitors and staff, effectively communicating the mission of Coastal Family Health Center (CFHC).
- Works closely with medical provider and other clinical personnel assigned to the care team to help ensure that patients have comprehensive and coordinated care.
- Acts as a patient advocate and liaison between the patient/family and community service agencies (i.e. schools, Department Human Services, Heath Care for Homeless, hospitals, support groups, etc.).
- Records patient care management information in the EMR and other HIT software no later than 24 hours after patient contact.
- Attends regular staff meetings, trainings and other meetings as requested.
- Manages assigned caseload of patients.
Perform other duties as assigned.