SUMMARY:

The Lead Community Health Worker (CHW) oversees a CHW program that addresses a specific social determinant of health (SDOH) and becomes an El Centro service line/offering such as Food Insecurity and Nutrition. Specifically, the Lead CHW is responsible for implementing the CHW program by providing administrative, operational, and programmatic activities This position identifies new community partners, and develops and maintains the relationship memorialized in a Memorandum of Agreement or Understanding (MOA/MOU) that complements El Centro’s activities to address Food Insecurity and Nutrition in Houston’s East End. The Lead CHW handles logistics with healthy food sources/providers that provide direct services to patients and community residents. In addition, this position supervises CHWs assigned to the program.

The Lead CHW also provides direct services and helps patients and their families to navigate and access mainstream and community services, and other resources while adopting healthy behaviors. The CHW supports El Centro’s providers through an integrated approach to care coordination, care management, and community outreach. As a priority, activities promote, maintain, and improve the positive health outcomes of El Centro’s patients, their families, and East End residents. CHW provides social support and informal counseling, and advocates for individuals and community health needs.

ESSENTIAL DUTIES AND RESPONSIBILITIES:

• Responsible for establishing trusting relationships with new and current partners that help El Centro achieve its goals regarding Food Insecurity and Nutrition.
• Prepares reports as well as manages program data.
• Responsible for establishing trusting relationships with patients and their families while providing general support and encouragement.
• Provide ongoing follow-up, basic motivational interviewing, and goal-setting with patients/families.
• Follow–up with patients via phone calls, home visits, and visits to other settings where patients can be found.
• Help patients set personal health-related goals and attend appointments.
• Provide referrals for services to community resources as appropriate.
• Help patients connect with transportation resources and provide appointment reminders in special circumstances.
• Exhibit excellent working relations with patients, visitors, and staff.
• Effectively communicating El Centro’s mission.
• Work closely with medical providers to help ensure that patients have comprehensive and coordinated care plans.
• Work collaboratively with other clinical personnel assigned to the same patient.
• Knowledgeable about community resources appropriate to the needs of patients/families.
• Responsible for providing consistent communication to the Case Manager or Care Coordinator to evaluate patient/family status, ensuring that provided information, and reports clearly describe progress.
• Act as a patient advocate and liaison between the patient/family and community service agencies.
• Record patient care management information in the EHR and other software no later than 24 hours after patient contact.