Community Health Worker

JOB PURPOSE:

Reporting to the ACO Lead and working under the direction of the care manager, the Community Health Worker supports implementation of the patient’s integrated care plan and works towards resolution of patient needs/barriers. The Community Health Worker facilitates communication between patients, their families, caregivers, providers, and other members of the health care team. The community health worker carries out delegated functions related to disease states and other conditions that have been deemed to be part of the scope of practice for unlicensed staff members. Their focus is to offer individualized assistance to patients, families and caregivers in order to help overcome health care system and community barriers and help facilitate consistent and timely medical care across the continuum of care. Community health workers function as members of the integrated care delivery team.

DUTIES AND RESPONSIBILITIES:

•          Perform Health Risk Assessments.
•          Provide general care management orientation to patients and communicate the goals and objectives of the program.
•          Provide assistance for patients referred to/from providers, care managers, and from other points of entry.
•          Assist with scheduling medical and specialty appointments. Provide reminder phone calls for appointments and/or follow-up calls post appointment.
•          Contact patients to facilitate continuity of care and escalate issues to Care Manager.
•          Compile and distribute educational material per patient need in consultation with Care Manager.
•          Assist patients with adherence to existing self-management goals or development of new goals (in collaboration with Clinical Staff.)
•          Assist in identifying individual and/or community needs which encourage healthy lifestyles and environments (i.e., community resources, transportation assistance, exercise programs, etc.).
•          Interact with the multidisciplinary team on behalf of the patient to resolve barriers. Communicate outcomes to patient/family/caregivers.
•          Assist in the collection and assembly of quality improvement information for the purpose of tracking and trending.
•          Participate in cross-functional team meetings aimed at improving patient outcomes or operational progresses.
•          Regularly participates in care team huddles with care managers to identify priorities, tasks and interventions.
•          Maintain timely and appropriate documentation on patient interactions in the care management system.
•          Develop and maintain excellent working knowledge of common chronic conditions and seek information as part of continuous learning.
•          Provide disease specific and preventive care patient education.
•          Ensure timely follow up with provider post hospitalization/emergence room visit.
•          Retrieve discharge summaries and copies of medical records.
•          Make home and facility visits, if necessary, to ensure patients are following their plan of care.
•          Perform population management activities as assigned.
•          Participate in designated activities and projects for PCMH as assigned by Medical Director.
•          All other duties as assigned