Community Health Worker

About the Role

The Community Health Worker Apprentice is a member of the community health team, an interdisciplinary team comprised of Community Health Workers, Behavioral Health Clinicians, and practice-based Nurse Care Managers. This role involves working closely with core team members to support patients dealing with complex medical, behavioral health, and/or substance issues, as well as social determinants of health. The Community Health Worker plays a critical role in assessing patient needs, offering community resources and referrals, providing navigation, support, care coordination, and ongoing case management. Visits are conducted in patients' homes and communities, using culturally sensitive approaches to improve health literacy. The role facilitates patient decision-making and self-management to help patients engage in their overall health and achieve their health goals.

This individual will track patient-related activities, monitor and document progress, and collaborate with the primary care team to promote patient-centered care. The Community Health Worker will also actively participate in multidisciplinary patient-centered team meetings and maintain frequent contact with community agencies to improve population health.

Responsibilities

• Initiate outreach and successfully engage with patients to enroll in the community health team program, scheduling appointments and providing follow-up contact within designated timeframes.
• Complete initial intake, including a comprehensive assessment of social needs, functional assessment of the patient in the home setting, and condition of the home if needed within designated timeframes.
• Build trusting relationships and serve as an advocate and mentor to empower patients to become more independent and self-sufficient.
• Collaborate with nurse care managers, physicians, other care team members (Medical Assistants, Nurses, etc.), hospitals, partner agencies, and members of the CHT in the patient’s network of care to improve patient care.
• Obtain releases, gather PHI from outside providers involved in patient care as needed, and process documents according to program requirements.
• Accompany patients to doctor’s appointments, assist with food planning/shopping, picking up prescriptions, completing forms for benefit applications, and assist with other tasks as needed.
• Educate patients on appropriate Urgent Visit and ED use.
• Utilize a multi-disciplinary team approach to address opportunities to plan and coordinate care.
• Use Motivational Interviewing skills and other patient engagement techniques with patients and caregivers.
• Assist in the development of a patient care plan to improve the patient’s health status and remove barriers preventing access to high-quality and timely primary/specialist care.
• Leverage EMR/chronic disease registry reporting to prioritize patient follow-up.
• Identify and utilize culturally sensitive approaches and community resources.
• Document activities and communications in the patient registry as defined by program requirements.
• Provide training to other team or practice staff as needed.
• Act as liaison to health plans, hospitals, long-term care, BH specialists, and home health representatives.
• Attend required training and collaborative sessions as scheduled.
• Perform other related duties as requested and serve on various system-wide committees.

Requirements

• High school graduate or GED required.
• Must have resided in the Greater Olneyville community (02909 zip code) for two years and have knowledge of community resources.
• Valid driver’s license with reliable transportation and proof of minimum auto insurance required.
• Bilingual Spanish required.
• Knowledge of Medicaid and Managed care preferred.
• Effective communication skills and ability to engage patients to work with the care team.
• Ability to work independently and collaboratively.
• Demonstrated cultural competence of the community.
• Complete the Community Health Worker Apprenticeship within one year of hire.
• Complete 2,000 hours of supervision, 144 hours of classroom training in Community Health Worker Competencies, and apply for the Community Health Worker Certification, if not already certified.

About Us

Care New England Health System (CNE) and its member institutions—Butler Hospital, Women & Infants Hospital, Kent Hospital, VNA of Care New England, Integra, The Providence Center, and Care New England Medical Group—is a trusted, integrated health care organization that fuels the latest advances in medical research, attracts the nation’s top specialty-trained doctors, hones renowned services and innovative programs, and engages in important discussions about health and end-of-life wishes. Care New England is helping to transform the future of health care, providing a leading voice in efforts to ensure the health of the individuals and communities we serve.