South County Health
Certified or within 12 months
Lived experience similar to population served
The South County Home Health Community Health Worker (CHW) has two main areas of focus, working with individuals and their families within their homes and working within community settings such as senior centers or other community -based organizations (CBO). The CHW deployed for this grant will be members of the South County Health Community Health Team (CHT); an interdisciplinary team comprised of CHWs, Peer Recovery Specialists (PRS), Behavioral Health Care Managers (BHCM), home health staff and practice-based Nurse Care Managers. The CHW will receive referrals from Home Health team leads, primary care nurse care managers and CBO’s across Washington County, as well as from the hospital system, for individuals and families living in Washington County or nearby Kent County.
The CHW works collaboratively with the home health and primary care teams to promote patient-centered care and actively participates in multidisciplinary patient-centered team meetings. The CHW has frequent contact with many community-based organizations on behalf of the patients served; advocating, networking and collaborating on resource identification to improve the overall health of the population.
ESSENTIAL DUTIES AND RESPONSIBILITIES include the following. Other duties may be assigned.
- Participate in the SCHH COVID Response and Resilience Implementation Team and work in collaboration with partnering organizations.
- Provide outreach and follow-up to patient referrals from SCHH team leads, community nurse and other referral sources.
- Successfully engage patients and families to assess and support SDOH needs.
- Complete initial intake and documentation, including a comprehensive assessment of social needs, functional assessment of the patient in the home setting, and condition of the home as needed.
- Build trusting relationship and serve as an advocate and mentor with the goal of empowering the patient to become more independent and self-sufficient.
- Provide community linkages and navigation to resources to address needs and barriers to health.
- Collaborate with SCHH nurses, PT, OT and team leads, PC nurse care managers, other care team members (Medical Assistants, Nurses, etc.), hospitals, partner agencies, members of the CHT in the patient’s network of care to improve patient care.
- Accompany patients to doctor’s appointments, assist with food planning/shopping, picking up prescriptions at the pharmacy, completing forms for benefit applications, and assist with other tasks as needed that support their medical, behavioral health and social needs.
- Engage patients and families in health coaching efforts to develop and maintain health & wellness.
- Attend CHW CORE training and/or Specialty training as required and appropriate to the population served, e.g. Older Adults, CVD/DM, Chronic Pain Self-Management.
- Achieve and maintain certification
- Attend monthly networking meetings convened by CHWARI for support, collective problem solving and share resources.
- Participate in the implementation of high impact strategies and activities to demonstrate the effectiveness of CHWs.
- in SCH leadership meetings (such as huddles) as CHW representative to lend professional experience.
- Participate as CHW representative in COVID response and recovery planning tables and other RIDOH sponsored meetings to regularly share community trends and support initiatives of the project.
- Participate with RIDOH in deployment to places where vaccine outreach is happening
- Support SCHH in implementing COVID resilience and response protocols and policies/procedures.
- Participate in qualitative and quantitative data collection to evaluate effectiveness of CHW strategies on client needs, services provided and other data points of interest.
QUALIFICATIONS FOR POSITION: Certification in Community Health Worker or working toward certification within 12 months required. Lived experience related to the population served by South County Home Health.
SKILLS & KNOWLEDGE REQUIREMENTS: To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
- Experience in healthcare related to community health or case management
- Ability to work independently and collaboratively in a team environment to achieve program goals.
- Ability to relate to patients and build trusting relationships.
- Ability to maintain confidentiality
- Ability to communicate effectively with co-workers, patients, family/care givers, and partner agencies.
- Strong time management and organizational skills.
- Exercise sound judgment and decision-making.
- Ability to assess and differentiate priorities.
- Strong interpersonal skills.
PERSONAL QUALITIES: The Community Health Worker must be a self-starter, able to work autonomously and also as part of a team, open to taking on challenges and participate in constructive problem-solving.
AMOUNT OF TRAVEL AND ANY OTHER SPECIAL CONDITIONS OR REQUIREMENTS: this county-wide project will require travel throughout southern Rhode Island and to Providence on an as-needed basis.
SALARY RANGE: $22-$25
HOURS PER DAY OR WEEK: 40 hours per week.