Our client is in search for a Community Health Worker (CHW) to work under the general supervision of the RN Program Manager. The CWH will support patients by providing basic community outreach services and assisting with programmatic interventions (connections to community-based organizations and social services) necessary in coping with the transition from hospital to community, specially related to social determinants of health and those barriers to care and health. This position will maintain regular hospital hours (in bedded model) and an assigned caseload and will conduct regular home visits and patient assessments.
The primary responsibilities of this position are:
- Work closely with hospital partners and hospital teams to participate in the Health-Related Social Needs screening process;
- Conduct home and community visits to identified patients to introduce the program and confirm patient needs (identified in the HRSN screener);
- Assist patients with the identification of appropriate community resources, on an ongoing basis (i.e. transportation, utility assistance, food, housing, health insurance, etc.)
- Communicate general service information to individuals and families on objectives and services, eligibility requirements and benefits;
- Refer eligible patients to necessary community based social services, identified via the resource database;
- Complete documentation of services provided, and efforts made in appropriate databases;
- Remind patients of and attend scheduled medical or community resource appointment, as needed.
- Prepare written reports and maintain records of outreach contacts and activities; and
- Participate in required program trainings, partner and staff meetings, workgroups (as needed), etc.