Community Health Worker

About the role

The Community Health Worker provides intensive case management services to individuals who have a Health Needs Based criteria (HNBC) and risk-factor as defined by Mass Health. The Community Health Worker will support the Community Support Program (CSP) and Health Related Social Needs (HRSN) Supplemental Housing Services provided through MassHealth.

Responsibilities

• Collaborates with PCP and other providers, including but not limited to community resources, to assure appropriate referrals based on the level of care needed which optimizes outcomes and minimizes risk.
• Assists members in improving daily living skills so members are able to perform them independently or access services to support them in doing so.
• Provides temporary assistance with transportation to essential medical and behavioral health appointments while transitioning to community-based transportation resources (e.g., public transportation resources, PT-1, etc.).
• Accompanies members to essential health care appointments, as needed.
• Assists with obtaining benefits, housing, and health care.
• Collaborates with Emergency Services Programs/Mobile Crisis Intervention (ESP/MCIs) and/or outpatient providers; including working with ESP/MCIs to develop, revise and/or utilize crisis prevention plans and/or safety plans.
• Drives referrals to any community or social services that align with a member's needs and goals.
• Conducts initial and ongoing risk assessment, designs personal crisis management plans, relapse prevention and harm reduction strategies with team clinician.
• Provides Pre-Tenancy Supports, including helping members identify housing preferences, assistance with budgeting or referral to housing financial aid programs, ensuring completion of subsidized housing applications, support with required follow up to applications and connection to community resources to access safe temporary housing.
• Provides Tenancy Transition Services to individuals moving to new home environments to include lease negotiations, necessary accommodations, budgeting and rental payment plans, access to needed furniture, equipment and in home health services.
• Provides Tenancy Sustaining supports to individuals with at risk tenancies include negotiating with landlords regarding accommodations, connecting to tenancy sustaining benefit programs, providing education regarding lease compliance, and connecting to legal, financial and other resources required for successful community living.
• Performs outreach to assigned members to complete housing assessments and design targeted housing plans.
• Completes in home assessment to determine remediation needs as needed and arranges for reputable contractor to address identified remediation need(s).
• Identifies the need for and coordinates Home Modifications that ensure the member’s health, welfare, and safety, or enables the member to function independently in a community-based setting, in coordination with the NE Director of Care Coordination.
• Uses evidence-based and promising practices that optimize care integration and effective communication across systems of care, and that align with rehabilitation, recovery, and wellness principles, such as the Housing First approach to care.
• Fosters empowerment, recovery, and wellness, including forming connections to recovery-oriented peer support and/or self-help support and services.
• Manages all care transitions through collaboration with members, community provider staff, ICT, and hospital staff to ensure a safe discharge plan and a well-coordinated implementation of that plan.
• Completes required Service Notes and case documentation in electronic health record to ensure accurate and timely billing of services.
• Participates in routine multidisciplinary team meetings.
• Completes all assigned courses on Vinfen Learning Management System and other training/in-service/workshops in best practices as assigned by supervisor.
• Uses recovery-oriented, person-centered, culturally competent, and strengths-based approaches to help members find, get, and keep housing.
• Ensures all members are consistently provided with trauma informed and culturally responsive services.
• Performs other related duties, as assigned.

Qualifications

• Typical Requirements: Experience with and knowledge of affordable housing services and resources. Experience working with people living with Serious Mental Illness (SMI) and/or Substance Use Disorder (SUD).
• Preferred /Required Education: A Bachelor's or Master's degree in Mental Health, Social Services, or Criminal Justice preferred. In some cases, experience may be considered a substitute for academic training.
• Driving Requirements: Driving is a requirement for this position using either a Vinfen van or personal vehicle. - If using a personal vehicle, you must possess and maintain adequate insurance as well as maintain a safe driving record which is subject to annual checks. A valid driver's license must be presented at the time of employment. Incumbents must be at least 21 years of age, have maintained a valid US driver's license for at least one year, and must be able to pass a driver's screening background check.