Integrated Care Team - Community Health Worker

Greater Lawrence Family Health Center, Inc.; Methuen (MA); On-site; USD 42,000 - 60,000; Full time

Job summary

Greater Lawrence Family Health Center, Inc. in Methuen, MA seeks an ICT Community Health Worker to support care coordination, HRSN assessment, and patient engagement across the care continuum.

You will collaborate with the Integrated Care Team to develop and monitor care plans, connect patients to housing, food, and community supports, and guide transitions of care while maintaining documentation in the EHR.

Qualifications

• CHW Certification required with commitment to obtain certification within 6 months of hire.
• CPR Certification required.
• Bilingual English/Spanish speaking preferred.
• Knowledge of community resources and ability to assess and implement based on assessment.
• Strong problem solving and critical thinking; escalation as needed.
• Experience in a multi-disciplinary team.
• Experience with patients with chronic medical and behavioral health needs.
• Experience with diverse populations and workforce.
• Flexible and adaptable to change.
• Strong organizational skills and ability to multitask and work independently.
• Ability to work independently while collaborating as needed.
• Excellent interpersonal communication and written skills.
• Desire to help patients in a non-judgmental and empathetic way.
• Cultural competence with diverse populations; valid driver's license and transportation.
• Proficiency with telehealth technologies and travel to patient homes.

Responsibilities

• Screen positive patients and formulate care plans addressing goals.
• Provide health education and assist with housing, finances, food, utilities, education, and community supports.
• Monitor progress and coordinate referrals per plan of care.
• Communicate patient updates to ICT team and adjust plans as needed.
• Complete necessary documentation (utility assistance, SNAP, disability, housing).
• Establish trusting relationships and engage hard-to-reach patients.
• Conduct home visits and accompany patients to appointments to ensure adherence.
• Follow up on referrals and warm handoffs for additional care coordination.
• Support transitions of care post-discharge and post-visit planning.
• Participate in ICT meetings and quality improvement efforts.
• Educate patients on using telehealth tools and devices.

Skills

Bilingual English/Spanish

CPR Certified

Community Health Worker Certification

Microsoft Office

Interpersonal communication

Problem solving

Organizational skills

Education

Community Health Worker Certification

CPR Certification

Tools

Microsoft Office (Word, Excel, PowerPoint)

Job description

Position Summary

Under the leadership and direction of the Director of Population Health, and in collaboration with Integrated Care Team leadership, the ICT Community Health Worker plays a pivotal role in supporting care coordination functions, including but not limited to assessment and care planning for patients screening positive for Health Related Social Needs (HRSN), patient engagement strategies, and transitions of care management. The ICT CHW serves as a liaison between the ICT members and external community-based service providers as needed, based on the needs of the patients. The ICT CHW is committed to continuous professional development within its scope of practice, including acquires and maintaining certification and additional training as applicable. As a care coordinator, manages a caseload of patients and follow them longitudinally to facilitate care planning and achieve goals.

Job Responsibilities and Performance Standards

HRSN Screening and follow-up Management

• For positive screening results, further assess and formulate a plan of care in order to address patient goals.
• Implement the plan of care, including providing health education, facilitating access to needed services such as assists patients in obtaining or stabilizing housing, finances, food, utilities, educational/vocational opportunities, and community supports.
• Monitor patient progress over time, including making referrals to service providers and coordinating care as needed per plan of care-established goals.
• Communicates patient updates to the ICT team and modifies plan of care as needed
• Completes necessary documentation, i.e. (utility assistance, SNAP, disability, SSI, DTA, housing)

Engagement

• Establish trusting relations with patients to facilitate their connection to the primary care team.
• Implement patient engagement strategies for patients identified as hard to reach and pose barriers to primary care access.
• Conducts home visits and accompanies patients to appointments as needed to ensure compliance
• Updates ICT on outcomes of related engagement strategies
• Follow up on referrals from the population health team on hard- to -engage patients with quality gaps
• Refers clients to outreach and enrollment for health insurance coverage
• Follow up on warm handoff referrals from care management for patients who require additional care coordination beyond the acute phase.

Transitions of Care

• Follow up on patient referrals generated by the central population health TOC team to ensure post- discharge, risk mitigation strategies, including, but not limited, to posy-discharge follow-up appointments and resumption of home-based services.
• Escalate to the primary care team any barriers that affect the potential for re-admission or preventable ED utilization.
• Providers transitions of care updates to the integrated care team, including participation in pre-visit planning activities
• Engages (outreaches) with patients between visits either by phone, home, or community visits.
• Supports efforts to meet identified key performance indicators and quality metrics; participates in quality improvement efforts
• Uses strategies such as motivational interviewing, harm reduction, and strengths-based approaches to support members in attaining stated goals
• to improve skills and role-specific certifications or specialization
• Educates patients how to utilize mobile devices or computers for telehealth appointments.
• Ensures appropriate documentation of visits and activities with EHR; documents visit, phone calls and any contact.
• Performs chart reviews.
• Participates in ICT meetings.
• Complies with all applicable organizational and departmental policies.
• Other duties as assigned.

Qualifications and Experience

• Community Health Worker Certification required including a commitment or willing to obtain certification within 6 months of hire.
• CPR Certified.
• Bilingual English/Spanish speaking preferred.
• Working Knowledge of community resources and ability to assess and implement based on assessment.
• Effective problem solving and critical thinking skills including need for escalation.
• Demonstrated success in working as part of a multi-disciplinary team.
• Experience working with patients with chronic medical and behavioral health needs.
• Demonstrated experience working with diverse patient populations and workforce.
• Must be flexible and adaptable to change.
• Strong organizational skills with ability to prioritize, multi-task and independently manage work demands, including escalation to supervisor when needed.
• Demonstrate the ability to work independently, while collaborating as needed with others if needed.
• Must demonstrate excellent interpersonal communication and written skills.
• Additional desirable qualities include enthusiasm and passion for helping patients in a non-judgmental and empathetic nature.
• Must demonstrate the basics of cultural competence when dealing with a diverse population.
• Must have a valid driver's license and access to reliable transportation.
• Must demonstrate a working knowledge of Microsoft Office: Word, Excel, and PowerPoint.
• Must be willing to learn and utilize telehealth technologies (video, chat), for a variety of services.
• Willing and able to travel to patients’ homes, and in the community as needed, based on patient’s needs.

#GLFHC offers a great working environment, comprehensive benefit package, growth opportunities and tuition reimbursement.