JOB SUMMARY

The Community Health Worker (CHW) will work closely with medical providers, primary care teams, and social services agencies to provide short term care coordination and connection to resources and support to program patients to improve their health and general well-being through education and provision of coordination of care and services. Reliable transportation for community outreach, such as home visits, health screenings and events is required. In addition to working at the Mid Valley (MVP) clinic, this position will also be required to float between the Wilkes Barre (WBP) and Scranton (SCP) clinics and the Driving Better Health (DBH) van.

REPORTING RELATIONSHIPS

This position reports to the Director of Patient Centered Services and Outreach and Co-Director of Patient and Community Engagement. No other positions report to this position.

ESSENTIAL JOB DUTIES and FUNCTIONS

• Assists patients in their homes, community, or clinic setting. Communicates to patients/patients the purposes of the program and the impact it may have on their wellbeing
• Helps patients identify socio-economic issues that affect their overall health and develop health/social management plans and goals
• Documents patient encounters and contacts made on behalf of patients in EMR; completes and submits monthly reports; maintains comprehensive electronic patient files, which include patient notes, release of information, assessments and other medical documents acquired on behalf of the patient
• Educates patient on the proper use of the Emergency Department and provides information for alternatives. Coaches patients in effective management of their chronic health conditions and self-care. Assists patient in understanding care plans and instructions. Motivates patients/patients to be active and engaged participants in their health and overall wellbeing. Connects with Hotspotting Teams to connect patients with enabling services
• Provides support and advocacy during initial medical visit or when necessary to assure patients' medical needs and referrals required are being conveyed. Follows up with both patients and providers regarding health/social services plans
• Continuously expands knowledge and understanding of community resources and services. Facilitates patient access to community resources, including locating housing, food, clothing, prenatal classes, parenting, and relevant mental health services. Assists patients in utilizing community services, including scheduling appointments with social services agencies and assisting with completion of applications for programs for which they may be eligible
• Facilitates communication and coordinate services between providers and the patients/patients. Coordinates and monitors services, including comprehensive tracking of patients' compliance in relation to care plan objectives
• Works collaboratively and effectively within a team. Establishes positive, supportive relationships with participants and provides feedback to other members of the team. Builds and maintains positive working relationships with the patients, providers, care managers, medical residents, and office staff. Works to reduce cultural and socio-economic barriers between patients and institutions
• Demonstrates positive working relations with patients, visitors, and staff to effectively communicate The Wright Center's mission
• Attends weekly huddles and morning/afternoon mini huddles
• Performs miscellaneous job-related duties as assigned

Qualifications:

• High school diploma or GED; at least 3 years of experience directly related to the duties and responsibilities specified
• Current BLS certification
• Completed degree(s) from an accredited institution preferred
• Must obtain CCHW certification within one (1) of employment
• Bilingual highly desired
• Strong interpersonal and communication skills and the ability to work effectively with a wide range of constituencies in a diverse community
• Knowledge of community agencies and resources
• Working knowledge of patient centered medical home model and multi-system outreach programs related to health care delivery, clinical education, and health-related services
• Ability to plan, implement, and evaluate individual patient care plans
• Knowledge of transportation and other barriers to care that may be encountered by patient
• Ability to communicate medical information to health care professionals and care coordinators over the telephone
• Basic computer skills
• Skill in organizing resources and establishing priorities
• Creative and analytical thinking

Metrics

• Conducts five warm hand offs between provider and referred services monthly
• Links 10 patients monthly to extended services (e.g., nutrition counseling, dental, smoking cessation, cardiac education, WIC)
• Makes 2 referrals monthly for Maternal and Family Health Services
• Conducts a minimum of 3 social and economic determinants of health (SEDH) screenings weekly (12 monthly)
• One monthly food pantry distribution with data collection on consumers served

PHYSICAL REQUIREMENTS/WORK ENVIRONMENT

The physical demands and work environment described here are representative of those that must be met by an employee to successfully perform the essential functions of the job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.