Population Health Specialist II

Millennium Physician Group•New York, NY

About The Position

Part of what makes a Community Health Worker such an effective member of a health care delivery team is the flexibility and diversity of what they can do within the clinic and in the community. There is a wide range of activities, tasks, and responsibilities a CHW (Community Health Worker) can take on in the healthcare setting. The primary responsibilities of a CHW are to build trusting relationships with clients and to connect those clients to care, eliminating barriers and advocating for systemic changes along the way. The effectiveness of CHWs lies in their ability to gain access to hard-to-reach individuals and to patiently coach and support them as they work towards health care goals.

Requirements

Community Health Worker
The role of the CHW includes the following:
CHWs in HCH programs work to guide patients experiencing homelessness toward more permanent primary care services outside the hospital system.
CHWs can serve as a liaison between multiple services and help with care coordination and care transitions for their clients.
In addition to connecting clients with health care services, CHWs work to connect clients with various social service programs for which they may be eligible.
CHWs’ lived experience of homelessness helps them build rapport with clients while also informing policies, procedures, and practices within the HCH clinic.
CHWs have a unique insight into the perspectives of their clients which helps them identify barriers or unmet needs within the HCH clinic that may go unnoticed by HCH clinicians or administrators.
CHWs amplify the voices of the community within their HCH clinics thereby informing health professionals of the evolving needs and conditions of their target population.
Community health workers typically do the following:
Coordinate care among individuals, communities, and health and social service systems
Conduct outreach, such as through home visits
Provide culturally appropriate health and informational resources
Oversee case management and resource access
Advocate for individuals and communities regarding housing, food security, and other needs
Provide coaching and social support, such as nutrition training, recovery services for mental health and substance use disorders, and chronic disease management and prevention
Provide services, such as basic health screenings and first aid
Community Health Workers work closely with other healthcare and social service providers, including Registered Nurses, Social Workers, Substance Abuse, Behavioral Health, and Mental Health Counselors.
Community Health Workers build trust and community capacity by improving the health and social welfare of the clients they serve.
Honesty: Community Health Workers are professionals that strive to ensure the best health outcomes for the communities they serve.
Confidentiality: Community Health Workers respect the confidentiality, privacy, and trust of individuals, families, and communities that they serve.
Scope of Ability and Training: Community Health Workers are truthful about qualifications, competencies, and limitations on the services they may provide, and should not misrepresent qualifications or competencies to individuals, families, communities, or employers.
Quality of Care: Community Health Workers strive to provide high-quality service to individuals, families, and communities.
Referral to Appropriate Services: Community Health Workers acknowledge when client issues are outside of their scope of practice and refer clients to the appropriate health, wellness, or social support services when necessary
Legal Obligations: Community Health Workers have an obligation to report actual or potential harm to individuals within the communities they serve to the appropriate authorities.
Cultural Humility: Community Health Workers possess expertise in the communities in which they serve.
Maintaining the Trust of the Community: Community Health Workers are often members of their communities and their effectiveness in providing services derives from the trust placed in them by members of these communities.
Respect for Human Rights: Community Health Workers respect the human rights of those they serve, advance principles of self-determination, and promote equitable relationships with all communities
Anti-Discrimination: Community Health Workers do not discriminate against any person or group on the basis of race, ethnicity, gender, sexual orientation, age, religion, social status, disability, or immigration status.
Client Relationships: Community Health Workers maintain professional relationships with clients.
Cooperation: Community Health Workers place the well-being of those they serve above personal disagreements and work cooperatively with any other person or organization dedicated to helping provide care to those in need.
Conduct: Community Health Workers promote integrity in the delivery of health and social services.
Wellness and Safety: Community Health Workers are sensitive to their own personal well-being (physical, mental, and spiritual health) and strive to maintain a safe environment for themselves and the communities they serve.
Value Access: Community Health Workers strive to ensure equal access to all services.
Value Acceptance: Community Health Workers strive to remain open-minded and are accepting of others and our differences.
Value Advocacy: Community Health Workers advocate for communities, individuals and the field of community health work.
Value Excellence: Community Health Workers strive for excellence by providing quality services and the most accurate information available to individuals and communities.
Value Learning: Community Health Workers embrace learning as life long, including life experiences and traditional learning.
Value Partnership: Community Health Workers are partners in the design, implementation and evaluation of CHW programs.
Value Social Justice: Community Health Workers are agents of change.
Value Strength: Community Health Workers assist families to acknowledge strengths and build upon them.
Value Trust: Community Health Workers have earned the trust of individuals and communities.
Value Unity: Community Health Workers regardless of discipline, region of the country, job title, and work within or outside of traditional systems are unified in our work to reduce disparities.

Responsibilities

Create connections between vulnerable populations and the health care system
CHWs in HCH programs work to guide patients experiencing homelessness toward more permanent primary care services outside the hospital system. Establishing a secure, trusted connection with a primary care provider can help prevent persons experiencing homelessness from reliance on Emergency Departments to meet primary care needs.
Care coordination and care transitions for clients
The mobility of CHWs within their communities creates opportunities for more coordinated care. CHWs can serve as a liaison between multiple services and help with care coordination and care transitions for their clients. In the process of connecting clients with multiple services, CHWs build relationships with local agencies, advocating for their clients in the process. The more CHWs are involved in the community at large, the more effective the linkages between the community and the health care system become.
Assist clients with enrollment in programs and benefits for which they are eligible
In addition to connecting clients with health care services, CHWs work to connect clients with various social service programs for which they may be eligible. These programs and benefits can range from enrollment into SSI/SSDI to enrollment into a GED program.
Encourage cultural competence among health care professionals serving vulnerable populations
CHWs’ lived experience of homelessness helps them build rapport with clients while also informing policies, procedures, and practices within the HCH clinic. CHWs have a unique insight into the perspectives of their clients which helps them identify barriers or unmet needs within the HCH clinic that may go unnoticed by HCH clinicians or administrators.
Advocate for vulnerable populations within the health care system and the community at large
CHWs amplify the voices of the community within their HCH clinics thereby informing health professionals of the evolving needs and conditions of their target population.
Coordinate care among individuals, communities, and health and social service systems
Conduct outreach, such as through home visits
Provide culturally appropriate health and informational resources
Oversee case management and resource access
Advocate for individuals and communities regarding housing, food security, and other needs
Provide coaching and social support, such as nutrition training, recovery services for mental health and substance use disorders, and chronic disease management and prevention
Provide services, such as basic health screenings and first aid
Community Health Workers work closely with other healthcare and social service providers, including Registered Nurses, Social Workers, Substance Abuse, Behavioral Health, and Mental Health Counselors.
Community Health Workers build trust and community capacity by improving the health and social welfare of the clients they serve. When a conflict arises among individuals, groups, agencies, or institutions, Community Health Workers should consider all issues and give priority to those that promote the wellness and quality of living for the individual/client. The following provisions promote the professional integrity of Community Health Workers.
Honesty: Community Health Workers are professionals that strive to ensure the best health outcomes for the communities they serve. They communicate the potential benefits and consequences of available services, including the programs they are employed under.
Confidentiality: Community Health Workers respect the confidentiality, privacy, and trust of individuals, families, and communities that they serve. They understand and abide by employer policies, as well as state and federal confidentiality laws, that are relevant to their work.
Scope of Ability and Training: Community Health Workers are truthful about qualifications, competencies, and limitations on the services they may provide, and should not misrepresent qualifications or competencies to individuals, families, communities, or employers.
Quality of Care: Community Health Workers strive to provide high-quality service to individuals, families, and communities. They do this through continued education, training, and an obligation to ensure the information they provide is up to date and accurate.
Referral to Appropriate Services: Community Health Workers acknowledge when client issues are outside of their scope of practice and refer clients to the appropriate health, wellness, or social support services when necessary
Legal Obligations: Community Health Workers have an obligation to report actual or potential harm to individuals within the communities they serve to the appropriate authorities. Additionally, Community Health Workers have a responsibility to follow requirements set by states, the federal government, and/or their employing organizations. Responsibility to the larger society or specific legal obligations may supersede the loyalty owed to individual community members.
Cultural Humility: Community Health Workers possess expertise in the communities in which they serve. They maintain a high degree of humility and respect for the cultural diversity within each community. As advocates for their communities, Community Health Workers have an obligation to inform employers and others when policies and procedures will offend or harm communities or are ineffective within the communities where they work.
Maintaining the Trust of the Community: Community Health Workers are often members of their communities and their effectiveness in providing services derives from the trust placed in them by members of these communities. Community Health Workers do not act in ways that could jeopardize the trust placed in them by the communities they serve.
Respect for Human Rights: Community Health Workers respect the human rights of those they serve, advance principles of self-determination, and promote equitable relationships with all communities
Anti-Discrimination: Community Health Workers do not discriminate against any person or group on the basis of race, ethnicity, gender, sexual orientation, age, religion, social status, disability, or immigration status.
Client Relationships: Community Health Workers maintain professional relationships with clients. They establish, respect, and actively maintain personal boundaries between them and their clients.
Cooperation: Community Health Workers place the well-being of those they serve above personal disagreements and work cooperatively with any other person or organization dedicated to helping provide care to those in need.
Conduct: Community Health Workers promote integrity in the delivery of health and social services. They respect the rights, dignity, and worth of all people and have an ethical obligation to report any inappropriate behavior (e.g. sexual harassment, racial discrimination, etc.) to the proper authority
Wellness and Safety: Community Health Workers are sensitive to their own personal well-being (physical, mental, and spiritual health) and strive to maintain a safe environment for themselves and the communities they serve.
Value Access: Community Health Workers strive to ensure equal access to all services. All persons have the right to access health care, human services and support services needed to improve health.
Value Acceptance: Community Health Workers strive to remain open-minded and are accepting of others and our differences. We are inclusive and accepting on all levels.
Value Advocacy: Community Health Workers advocate for communities, individuals and the field of community health work. We develop the capacity of individuals and communities to advocate for themselves.
Value Excellence: Community Health Workers strive for excellence by providing quality services and the most accurate information available to individuals and communities.
Value Learning: Community Health Workers embrace learning as life long, including life experiences and traditional learning. We seek ongoing opportunities for education and training to expand our knowledge base.
Value Partnership: Community Health Workers are partners in the design, implementation and evaluation of CHW programs. Communities, families and individuals are partners in determining their needs. We pursue equitable partnerships with other professionals including health care and social service providers.
Value Social Justice: Community Health Workers are agents of change. We pursue social change through work with community members to improve social conditions.
Value Strength: Community Health Workers assist families to acknowledge strengths and build upon them. All communities and families have strengths.
Value Trust: Community Health Workers have earned the trust of individuals and communities. We respect that trust and work hard to maintain a trusting relationship with individuals and communities.
Value Unity: Community Health Workers regardless of discipline, region of the country, job title, and work within or outside of traditional systems are unified in our work to reduce disparities.