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Job Summary
The Community Health Worker Apprentice is a member of the community health team; an interdisciplinary team comprised of Community Health Workers, Behavioral Health Clinicians and practice-based Nurse Care Managers. Works closely with the core team members to support patients who are dealing with complex medical, behavioral health and/or substance issues as well as social determinants of health and require a more intensive home and community-based intervention. The Community Health Worker plays a critical role in assessing patient needs, offering community resources and referrals, providing navigation, support, care coordination, and ongoing case management to meet those needs. Visits patients in their homes and in the communities in which they live, providing culturally sensitive approaches to health information to improve health literacy. The Community Health Worker facilitates the patient's decision-making and self management to help patients engage in their overall health and achieve their health goals. This individual will be responsible for tracking patient related activities, monitoring and documenting progress. Works collaboratively with the primary care team to promote patient-centered care and actively participates in multidisciplinary patient-centered team meetings. The Community Health Worker has frequent contact with many community agencies on behalf of the patients served, networking and collaborating on resource identification to improve the overall health of the population.
Duties & Responsibilities
Initiates outreach and successfully engages with patients to enroll in the community health team program, scheduling appointments and providing follow-up contact within designated timeframes.
Completes initial intake, including a comprehensive assessment of social needs, functional assessment of the patient in the home setting, and condition of the home if needed within designated timeframes.
Builds trusting relationship and serves as an advocate and mentor with the goal of empowering the patient to become more independent and self-sufficient.
Collaborates with nurse care managers, physicians, other care team members (Medical
Assistants, Nurses, etc.), hospitals, partner agencies, members of the CHT in the patient's network of care to improve patient care.
Obtains releases, gathers PHI from outside providers involved in patient care as needed and processes documents according to program requirements.
Accompanies patients to doctor's appointments, assists with food planning/shopping, picking up prescriptions at the pharmacy, completing forms for benefit applications, and assists with other tasks as needed.
Educates patients on appropriate Urgent Visit and ED use.
Utilizes a multi-disciplinary team approach to address opportunities to plan and coordinate care.
Utilizes Motivational Interviewing skills and other patient engagement techniques with patients and caregivers.
Assists in the development of a patient care plan to include actions designed to improve
the patient's health status, and removes the barriers that are preventing them from gaining access to high quality and timely primary/specialist care.
Leverages EMR/chronic disease registry reporting to prioritize patient follow-up.
Identifies and utilize culturally sensitive approaches and community resources.
Documents activities and communications in the patient registry as defined by program requirements.
Provides training to other team or practice staff as needed.
Acts as liaison to health plans, hospital, long-term care, BH specialists and home health representatives.
Attends required training and collaborative sessions as scheduled.
Performs other related duties as requested and serves on various system wide committees
Requirements
High school graduate or GED required. Must have resided in the Greater Olneyville community (02909 zip code) for two years and have knowledge of community resources. Valid driver's license with reliable transportation and proof of minimum auto insurance required. Bilingual Spanish required. Knowledge of Medicaid and Managed care preferred. Effective communication skills and ability to engage patients to work with care team. Ability to work independently and collaboratively. Demonstrated cultural competence of community. Complete the Community Health Worker Apprenticeship within one-year upon hire. Complete 2,000 hours of supervision, complete 144 hours of classroom training in Community Health Worker Competencies, and apply for the Community Health Worker Certification, if not already certified.
About Us
Care New England Health System (CNE) and its member institutions, Butler Hospital, Women & Infants Hospital, Kent Hospital, VNA of Care New England, Integra, The Providence Center, and Care New England Medical Group, is a trusted, integrated health care organization that fuels the latest advances in medical research, attracts the nation's top specialty-trained doctors, hones renowned services and innovative programs, and engages in the important discussions people need to have about their health and end-of-life wishes. Care New England is helping to transform the future of health care, providing a leading voice in the ongoing effort to ensure the health of the individuals and communities we serve.
Americans with Disability Act Statement: External and internal applicants, as well as position incumbents who become disabled must be able to perform the essential job-specific functions either unaided or with the assistance of a reasonable accommodation, to be determined by the organization on a case-by-case basis.
EEOC Statement: Care New England is an equal opportunity employer. All applicants will be considered for employment without attention to race, color, religion, sex, sexual orientation, gender identity, national origin, veteran or disability status
Ethics Statement: Employee conducts himself/herself consistent with the ethical standards of the organization including, but not limited to hospital policy, mission, vision, and values.