Community Health Worker - One Care

Company: Lynn Community Health Center
Location: Lynn
Posted on: January 8, 2021

Job Description:

Full time Community Health Worker (CHW) at the Lynn Community Health Center (LCHC) needed to provide community and health center based support for LCHC high risk, and complex patients.The Community Health Worker (CHW) at the Lynn Community Health Center (LCHC) is part of an integrated and interdisciplinary care team working to address patients' health needs. The community health worker will provide culturally appropriate individual and group health education, coaching, informal counseling, case management, care coordination, and advocacy in order to promote, facilitate and improve access to ongoing primary and behavioral health care for members of the target population. The community health worker works with interdisciplinary care teams and other providers, as appropriate to promote, maintain, and improve the patient's health.The primary responsibility of the community health worker is to educate, advocate and coach patients who require additional support to meaningfully address medical, social, and psychological needs. The patient's behavioral /primary care provider takes the lead role in devising patient centered treatment or action plan(s) and identifying focus areas for the community health worker to work with the patient. The community health worker collaborates closely with the provider, nurse care manager, team nurse manager, and other members of the interdisciplinary care team. The community health worker works with the patient in clinic and community settings, as well as the patient's home.Additionally, the Community Health Worker participates in LCHC community outreach efforts, as appropriate and as assigned. This may include participating in health screenings, health education programs or counseling at health fairs and other similar community events. The Community Health Worker also plays an important role in the community on behalf of patients to provide assistance with skill building, facilitating linkages with other community based and natural support systems, and advocating for community needs.Grant Funded Positions****Employees hired for grant funded postions will be given priority for permanent opportunities.DUTIES AND RESPONSIBILITIES:

• Work with the patient and interdisciplinary care team to identify, develop and implement a cultural competent and patient directed/centered individualized treatment/care plan.
• Assist patient to follow treatment recommendations of the interdisciplinary team, practice healthy behaviors and access necessary social, medical, behavioral support services and programs.
• Conduct outreach and engagement activities that support patient continuity of care, including re-engaging patients in care if they miss appointments and/or do not follow up on treatment.
• Conduct an initial and periodic needs assessments, including assessing barriers and assets (e.g. transportation, community bariers, social supports); patient and family or caregiver preferences; language, literacy and cultural preferences.
• Promote patient treatment adherence through assessing patient readiness to make changes, assisting patient in making changes in daily routines, identifying barriers and assisting patients with developing strategies to address barriers.
• Meet face-to-face with patients according to frequency agreed upon by patient, supervisor, and interdiciplinary care team. Provide other support and follow up via telephone or mail contact as necessary.
• Collaborate with other providers, staff and community resources to enhance coordination, quality and efficiency in care.
• Communicate all changes and concerns to the behavioral health/primary care provider, nurse manager, and nurse care manager with whom (s)he shares patients.
• Conduct home visits alone or in conjunction with member(s) of the interdisciplinary team as appropriate and consistent with safety for the employee and patient.
• Provide culturally competent support, individual and group education, guidance, mentoring, and coaching regarding chronic disease management, comprehensive preventive care and self management goals.
• Organize and or facilitate health education groups that promote wellness.
• Assist patients with effectively navigating health care and social service systems, including arranging for transportation and accompanying patients to appointments as requested by care team.
• Support patients in preparing questions for provider's visit and assist patients in understanding care plans and instructions, and tailoring communications to appropriate health literacy level.
• Provide support for chronic disease self-management to individuals and their families.
• Show initiative in working creatively with patients to address their identified needs and help them move towards successful resolution of challenges.
• Consult and seek support from members of the interdisciplinary care team to enhance knowledge and foster professional growth.
• Provide culturally competent care coordination and support services for patients depending on individual needs and preferences.These include but are not limited to:
  • Link patients with resources and empower them to use them to their advantage
  • Advocate for individual and community health needs for the patient
  • Direct practical assistance, i.e. filling out forms, making appointments as appropriate
  • Coordinating interpreter services
  • Escort patients to pharmacy; grocery store; food pantry and other community locations as needed to meet goals of treatment/care plan
  • Network/collaborate with community leaders, area health providers, voluntary organizations and others who can contribute to ongoing assessment of the health needs of the target population.
  • Conduct community outreach to provide information/make referrals to/coordinate needed services
  • Identify community resources that provide needed support for patient
  • Provide health education to individuals and groups on prevention and public health risks and problems
  • Eeducate staff/providers about target population and community characteristics and needs
  • Participate in meetings with supervisor and attend team and staff meetings at the health center.
  • Participate in staff development trainings and external educational offerings to maintain and improve knowledge base.
  • Accurately document all patient interactions in a timely fashion in the designated electronic health record. Documentation includes but not limited to: care plan progress, telephone calls, home visits, time with providers, case management, travel time etc.
  • Keep logs, data on patient contacts, as required by funding source.SPECIFIC DUTIES AND RESPONSIBILITES:
    • Maintains a caseload of One Care members and develops and executes care plans for each in consultation with licensed Care Managers on One Care team.
    • Works with the patient in clinic and community settings, as well as the patient's home.
    • Assists One Care RNs with initial and annual care management assessments.
    • Utilizes EPM / EHR and CCA EMR (ECW) systems to enter appropriate data in designated templates as required by partnership contract.
    • Procures covered services and supplies for members and processes authorizations for such services in consultation with licensed Care Managers on One Care team and in accordance with CCA policies.
    • Completes tracking, utilization, enrollment, treatment and compliance reports, as requested.
    • Attend scheduled internal and external meetings and/or training sessions as requested.RequirementsQUALIFICATIONS:
      • Bachelor's degree in health sciences, social work, sociology, human services or related field preferred
      • Ability to work with and relate to individuals and families from diverse backgrounds and experiencesStrong knowledge of local community, social service, and cultural resources
      • Strong organizational, interpersonal, attention to detail, time management, multi-tasking, and problem solving skills
      • History of good attendance and positive work attitude
      • Excellent communication skills and ability to set personal boundaries
      • Ability to establish positive and supportive relationships with and among patients and colleagues
      • Ability to work independently and collaborate with a team
      • Ability to motivate others and thrive in a fast paced environment
      • Willingness to openly address and acknowledge issues of addiction, substance use and mental illness
      • Ability to develop, adapt, and execute outreach plans
      • Excellent English written and verbal skills
      • Computer literacy and ability to document appropriately in electronic health record
      • Must have a valid driver's license and transportation
      • Bilingual and multilingual candidates encouraged to applyEXPERIENCE AND TRAINING:
        • Three or more years experience as a community health worker or case manager in a community health setting; and/or related experience in health/human services, social services or advocacy.
        • Experience in outreach within mental health, community-based treatments or medical comorbidity.
        • Ability to openly address and acknowledge issues of addiction, substance use and mental illness.
        • Training and or certification as a community health worker preferred. Community health worker should obtain certification within one year of Massachusett's Department of Health certification approval and or within six months of hire, whichever comes first.
        • Experience providing health education and knowledge of health promotion/wellness preferred.Lynn Community Health Center (LCHC) provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to race, color, religion, sex, national origin, age, disability or genetics. In addition to federal law requirements, LCHC complies with applicable state and local laws governing nondiscrimination in employment in every location in which the company has facilities. This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, and transfer, leaves of absence, compensation and training. LCHC expressly prohibits any form of workplace harassment based on race, color, religion, gender, sexual orientation, gender identity or expression, national origin, age, genetic information, disability, or veteran status. Improper interference with the ability of LCHC's employees to perform their job duties may result in discipline up to and including discharge.Job Posting ID #: 20-148 , 20- 156HoursFull-Time

Keywords: Lynn Community Health Center, Lynn , Community Health Worker - One Care, Healthcare , Lynn, Massachusetts