The Community Health Worker (CHW) delivers culturally competent services to help patients and families navigate and access community services, other resources and adopt healthy behaviors. The CHW assists with care coordination tasks such as appointments and/or transportation, patient education and assistance with navigating physical and behavioral health systems, and facilitating communications with providers and other care team members. They will help patient’s self-management by evaluating their needs, assisting with plan development, and working towards patient-centered goals.

• Under the supervision of the Program Supervisor and dietitian, the CHW provides education to patients/families culturally and linguistically appropriate services
• Meets patients/families in various settings including in-office, community, and home and perform age appropriate structured assessments that include goal setting. Conduct intake/enrollment screenings and assessments that address access to the medical, behavioral and social needs of patients, in order to identify gaps in care and barriers to obtaining resources critical to the patients’ well-being
• Makes regular follow-up contacts to patients.
• Places referrals (and follows up) to applicable community based resources including housing supports, dietary resources, support groups, and financial supports.
• Assist with applications as needed for food, and nutrition benefits, housing, transportation, legal services; conduct warm handoff referrals to external agencies.
• Arranges and coordinates transportation as needed for patient to attend appointments.
• Motivates patients/families to meet their health goals, including assessing/addressing barriers to care.
• Collaborates with both internal and external provider groups; Participates in outreach activities as applicable
• Provides culturally sensitive services to patients from different cultures.
• Maintains timely and accurate documentation according to organization and program specifications
• Collaborate and communicate with the care team and participate in high risk meetings
• Other duties as assigned