Community Health Worker

InnovaCare•Lakeland, FL

About The Position

The Community Health Worker (CHW) provides care coordination and social services in support of clinical operations and care management teams. Under the supervision of the care management supervisor, the CHW works with medical providers, primary care teams, and social agencies to provide short-term care coordination and connect patients with resources and support programs that can improve their health and well-being. The CHW completes initial biopsychosocial assessments through telephone and face-to-face contacts at clinics, patients’ homes, and other locations. Assessments address home visits, safety, support systems, clinical or medical needs, and possible cognitive or behavioral changes, which are reported to the supervisor. The CHW develops plans to address patients’ social needs and supports patients and families through care transitions and ongoing care management. The role includes educating and coaching patients, coordinating and monitoring services, documenting encounters and outcomes, and connecting patients with community resources, prescriptions, durable medical equipment, and other services. Travel to clinics, homes, community locations, agencies, and other outreach destinations is expected about 40% of the time.

Requirements

Strong interpersonal and communication skills and ability to work effectively with diverse constituencies.
Knowledge of community agencies and resources.
Working knowledge of multi-system outreach programs related to health care delivery, clinical education, and health-related services.
Ability to plan, implement, and evaluate individual client care plans.
Knowledge of transportation and other barriers clients may encounter in receiving care.
Ability to communicate medical information to health care professionals and care coordinators by telephone.
Skill with personal computers and related software applications, including email.
Skill in organizing resources and establishing priorities.
Creative and analytical thinking.
Car and valid driver’s license.
Travel expected about 40% of the time.

Nice To Haves

Associate degree in Business Administration or a human service field, or training as a Paramedic or Certified Nursing Assistant.
Successful completion of a formal Community Health Worker training program, such as one offered by a college or other educational institution.
Medical terminology knowledge and background.
Ability to write and speak in English and Spanish.

Responsibilities

Provide services that facilitate patients’ psychosocial adjustment along the continuum of care and transition to the next level of care.
Develop effective relationships with patients, families, and case managers; engage and collaborate with patients and families, advocate for them, and help solve problems.
Assist patients in their homes and communities and explain the program’s purpose.
Educate patients about Advance Directives, assist with forms, and provide information about power of attorney (POA).
Assist patients with health-related social determinants and financial, emotional, and social issues.
Help patients identify socioeconomic matters affecting their health and develop health and social management plans and goals.
Connect patients and families experiencing significant emotional, social, environmental, or financial stress related to hospitalization or acute or chronic illness with community resources and continuing-care support.
Screen patients for the Falls Prevention Program.
Provide care appropriate to patients’ ages, applying knowledge of growth and development across the life span.
Observe patient-rights and regulatory and accrediting standards, including awareness of medical and legal issues.
Document client encounters and contacts made on clients’ behalf, complete and submit monthly reports, and document activities, service plans, and patient outcomes.
Educate clients about appropriate emergency room use and alternatives.
Coach patients in managing chronic health conditions and self-care, and help them understand care plans and instructions.
Motivate patients and clients to participate actively in their health and overall well-being.
Provide support and advocacy during initial home visits or when needed to ensure medical needs and required referrals are conveyed.
Follow up with clients and providers regarding health and social services plans.
Help ensure patients and families can access prescriptions, durable medical equipment (DME), and other identified services.
Facilitate communication and coordinate services between providers and patients.
Coordinate and monitor services and track clients’ compliance with care plan objectives.
Travel to clinics, patient homes, community locations, agencies, and other outreach destinations.
Perform miscellaneous job-related duties as assigned.