“Emergency Department to Community Connections and Re-engagement Community Health Worker”

Rhode Island Hospital


Full-time, Day Shifts


The ED-CARE (Emergency Department to Community Connections and Re-engagement) Community Health Worker will work with high utilizer patients in the Emergency Department (ED) at Rhode Island Hospital. The CHW should be a dynamic, motivated individual with thorough knowledge of local social services and community resources as well as have an interest in data analysis, trends, and outcomes. The goal of the ED-CARE Community Health Worker is to provide navigational, case management, and peer support services to patients who are high utilizers of the ED. These patients also have significant medical co-morbidities, mental health issues, and substance use disorders. Specifically, the role of the ED-CARE Community Health Worker is to assist with robust services for each assigned client while participating in data collection for program sustainability purposes.

The CHW should have an understanding of social determinants of health in health outcomes and health behaviors towards addressing disease. In addition, the applicant should have completed CHW training and have familiarity with and commitment to the CHW code of ethics.

A Community Health Worker is “a frontline public health worker who is a trusted member of and/or has an unusually close understanding of the community served. This trusting relationship enables the CHW to serve as a liaison/link/intermediary between health/social services and the community to facilitate access to services and improve the quality and cultural competence of service delivery. A CHW also builds individual and community capacity by increasing health knowledge and self-sufficiency through a range of activities such as outreach, community education, informal counseling, social support and advocacy.” (APHA CHW Section) Specifically, the role of the CHW is to:

  • Work collaboratively on an interdisciplinary team utilizing an integrated client care model in conjunction with best practices for Community Health Workers.
  • Engage in effective motivational interviewing, peer outreach, case management, and navigational services to Emergency Department patients with substance use, mental health and social needs.
  • Coordinate collaboration with the medical home-primary care (PCP), community services, case managers, and social workers, to deliver interventions that will address social needs and maximize patient health outcomes.


Under supervision of the CHW Supervisor and with oversight from the Center for Primary Care and the Emergency Department medical teams, the ED-CARE CHW is responsible for performing the following essential job functions:


  • Complete initial assessments with the patient and providers to identify specific areas of focus, patient strengths, and barriers to care for high utilizers of the ED.
  • Work to build a trusting and supportive relationship through continued rapport building techniques which you can develop goals for patient’s care.
  • Help patients develop and maintain systems to manage their care
  • Help to address any logistic barriers, scheduling complications, childcare needs, etc., that would prevent a patient from showing up to their appointments.
  • Accompany patients to appointments with health care and social services providers when needed to provide support and advocacy.
  • Establish and maintain communication with patient’s care team (existing health care providers, case workers, etc). Mobilize existing team members to action on behalf of the patient.
  • Document patient encounters and track benchmarks in progress.
  • Document care coordination notes in the electronic health record (EHR) for high risk patients.
  • Follow up with case load weekly by using a rating system which determines needs and priorities for each client.
  • Document clinically appropriate information in the hospital’s EHR
  • Complete data collection on each client and upload into a spreadsheet for monthly analysis of client progress, needs, and setbacks.
  • Shifts vary depending on emergency department statistics: some nights and weekends are required.
  • Compete other job duties as assigned.


  • Complete research/IRB training through Lifespan. Demonstrate privacy and confidentiality, meeting all related training and practice requirements of the Lifespan system
  • Enroll patients in the Emergency Department into ED-CARE
  • Administer research surveys to patients as necessary
  • Collect data weekly, monthly and quarterly
  • Work with Project Coordinator as necessary to fulfill the research components of the position


  • Two (2) years of verifiable experience in social services or health care preferred.
  • Two (2) years of community health-based client engagement
  • Understanding of trauma informed care and dealing with those who have critical needs
  • Completed CHW certification for the state of Rhode Island.
  • Effective communication skills with the ability to motivate individuals to develop priorities and effectively implement strategies to address social determinants of health.
  • Experience with motivational interviewing, advising/counseling clients, and/or participating in health promotion and health education activities.
  • Experience working with health care systems, substance use treatment programs, and/or community-based organizations.
  • Excellent verbal and written communication skills.
  • Excellent organization, thorough record-keeping, follow through, and ability to juggle multiple priorities in fast-paced environment with multiple collaborators.
  • Demonstrated excellent attendance and reliability.
  • Efficient computer skills, including Microsoft Office.
  • Experience using an electronic health record (EHR) or ability to learn how to use one.
  • Willingness to travel locally and to and work in various environments, including street outreach, home visits, homelessness encampments, and more.
  • Experience working with those living with severe medical and mental health issues who have significant barriers to various types of care.
  • Valid driver’s license and excellent driving record and reliable personal transportation.
  • Bilingual English/Spanish preferred

To Apply:

Email Lauren D’Andrea LCDP, CCS, CPRSS at