As an integral member of our Patient-Centered Health Home (PCHH) care team, the Community Health Worker (CHW) utilizes unique expertise to bridge the gap between clinical care, social services, and patients. Working directly within a multidisciplinary care team, the CHW conducts proactive outreach, facilitates care coordination, and provides health promotion services. This role focuses on closing care gaps, improving clinical outcomes, and optimizing the cost-effective use of healthcare resources through patient empowerment and social support navigation.
Key
Meet regularly with the care team to plan patient care, discuss active cases, and exchange clinical and non-clinical information as part of the daily practice routine. Conduct strategic outreach to actively engage patients in healthcare services and preventive care, successfully closing care gaps. Assist with the entry, navigation, referral, and tracking of both clinical needs and community social supports.
Provide culturally appropriate education on health conditions and practical strategies to implement treatment plans and care goals. Educate, coordinate, and provide access to chronic disease management, including teaching self-management support and training patients on self/home disease monitoring. Facilitate collaborative goal setting with patients, assess their self-management plan progress, and assist directly with medication or treatment adherence.
Work closely with patients to problem-solve and overcome daily obstacles to complying with a given clinical treatment. Co-lead health education groups and actively implement targeted wellness and prevention initiatives. Identify and maintain an updated network of community resources, social services, and educational workshops to maximize patient health and wellness.
Exceptional active listening and interpersonal skills with the ability to build trust with diverse populations. Strong collaborative skills to seamlessly integrate with clinical care team members in a fast-paced environment. Resourcefulness in navigating complex social service systems and overcoming patient barriers to care.
Basic computer skills and familiarity with tracking systems or Electronic Health Records (EHR) preferred.
High school diploma or equivalent required.
Prior experience working as a CHW, case management aide, or within a community-based public health or healthcare setting is highly preferred. Certification: Formal Community Health Worker (CHW) state certification or credentialing is highly preferred (or willingness to obtain certification upon hire with appropriate training).