Community Health Worker CMC
- Provide intensive outreach efforts by conducting home visits or visits to other appropriate settings to an identified patient population.
- Establish relationships with patients/families and provide general support and encouragement.
- Conduct intake interviews with patients using established protocols and intake tools.
- Work with patients and their physicians to develop personal health action plans that are achievable.
- Assist patients in addressing challenges to care for transportation, language, family/social support.
- Schedule appointments and perform reminders for patients. Ensure appropriate resources are available for attending appointments.
- Follow-up with patients by letter, phone call, text or home visit on missed appointments or referrals.
- Assist patients with comprehension of health insurance eligibility, benefits and navigation.
- Educate patients on self-care, healthful living, setting and achieving goals, using/reinforcing SUHI’s clinical education protocols, APP’s evidence-based tools or other, evidence-based tools.
- Refer patients to community-based resources to adhere to physician recommendations.
- Alert APP clinical team on patient needs, concerns, and interests. Ensure continuity of care.
- Keep accurate records of patient contacts and document patient needs, action plans, and follow up needs in appropriate database or electronic medical record.
- Health Education
- Provide health education activities for identified health concerns such as Asthma, Diabetes, Hypertension and other chronic diseases.
- Provide informal counseling, education, and social support to assist patients with gaining access to continuous care and enabling services.
- Coach/encourage patient self-management and adherence to clinical recommendations for identified health concerns such as Asthma, Diabetes, Hypertension and other chronic diseases.
- Community Outreach & Advocacy
- Develop and maintain strong working relationships with external (e.g., referral sources and community agencies) and internal contacts (care team) through direct contact including participating in community meetings and care team huddles.
- Share information and resources, collaborate on initiatives and provide education to referral sources and community agencies in order to coordinate access to services.
- Collect and organize information to be used for current services and future community health education and outreach activities.
- Program & Care Team Operations
- Participate in care team huddles to understand and proactively respond to the needs of the patient population.
- In collaboration with the clinical team, identify, consolidate and manage a high-risk patient registry.
- Assist care team as needed and performs other duties as assigned.
- High School Diploma/G.E.D.
- Good communication skills. Ability to work as a team member.
- n/a
- Ability to lift up to 35 pounds without assistance. For patient lifts of over 35 pounds, or when patient is unable to assist with the lift, patient handling equipment is expected to be used, with at least one other associate, when available. Unique patient lifting/movement situations will be assessed on a case-by-case basis. Addendum: updated old jd for new APP position This job description indicates the general nature and level of work expected of the incumbent. It is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities required of the incumbent. Incumbent may be required to perform other related duties.
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