JOB SUMMARY:

The Community Health Worker (CHW) is part of the Hospital’s Community Care Team (CCT). CCT is a program focused on improving the health of complex, chronically ill Howard County residents. This program helps individuals connect with resources that allow them to better manage their illness, improve their health and avoid preventablehospital encounters. CCT helps clients to meet their goals by providing health education, teaching chronic-diseasemanagement skills, and by connecting them to a medical home and other community resources. The CHW is an integral part of the multi-disciplinary team that includes Community Health Nurses and a Licensed Clinical SocialWorker. CHW is responsible for initiating the development of a care plan with the client and his or her health care providers as well as monitoring its implementation and progress made toward goals. This position maintains anassigned client caseload and conducts regular home visits and assessments.

MAJOR JOB RESPONSIBILITIES:

Working closely with the Community Health Nurse, principal duties include the following:

1. Establishes trusting relationships with clients and their families while providing general support and encouragement
2. Provides ongoing follow-up, basic motivational interviewing and goal setting with clients/families
3. Conducts follow-up with clients via phone calls, weekly home visits and visits to other community settings
4. Assists clients to increase health knowledge and self-sufficiency through a range of activities such as outreach,community education, informal counseling, social support and advocacy
5. Conducts intake and needs assessments, including enrolling and/or referring clients to their primary care provider, and for services to community agencies as needed
6. Assists clients with scheduling and finding transportation to medical appointments and attendappointments with clients as appropriate
7. Works closely with medical provider(s) including providing reports of client progress to help ensure that patientshave comprehensive and coordinated care
8. Maintains extensive knowledge about community resources appropriate to needs of clients includingtransportation, home care, home modifications and social supports
9. Provides consistent communication to the Community Health Nurse regarding the client’s health status,barriers to good health and progress towards goals
10. Completes timely and accurate documentation of program activities
11. Serves as a preceptor for HCGH’s accredited CHW Training Program. Available to be shadowed by a student for one or more 40-hour practicums per cohort (in-person or virtual) that would include students attending home visits and/or virtual visits; observing how to Revised 7/11/2022 document in an EMR; administering a healthrisk assessment;