A Community Health Worker (CHW) is a trained advocate from the community who works in the field and coordinates care to help bridge the gaps and eliminate barriers to health care and social services for identified at-risk clients. A CHW conducts home and site visits to assess risks, match children, adolescents, and adults to identified/needed services, and empowers individuals to access community resources through referrals, education, and outreach. A CHW collects and reports specific health, behavioral, and social information, and assists clients by helping them access needed services efficiently. A CHW assists the health care team in recognizing potentially serious problems, thus preventing poor health and social outcomes for individuals and communities. The CHW takes direction from and is responsible to the members of the medical home care team, but directly reports to and takes direction from the RN Care Coordinator and embedded BH provider.
(May perform additional duties of similar complexity within SCHS as required or assigned)
Contacts identified clients by telephone, mail, and/or hospital or home visit. Makes additional follow-up contacts with clients as necessary. May arrange and/or supply transportation to critical appointments and interviews if necessary.
Collects and reports specific health, behavioral, and social information, and assists clients by helping them access needed services.
Completes global needs assessments to identify needs and potential eligibility for any programs and/or assistance for clients
Educates clients about available community resources and works to connect clients to local social service agencies. Provides relevant educational materials and social support
Assists clients in utilizing resources, including scheduling appointments, accompanying clients to appointments as needed, and assisting with completion of applications for programs for which they may be eligible
Assists the health care team in the SCFC medical home/team care model in recognizing potential serious problems, in prevention of poor health and social outcomes for individuals and communities
Facilitates access to health related services, including but not limited to: assisting clients with obtaining a medical home, providing instruction on appropriate use of the medical home, assisting patients in overcoming barriers to obtaining needed medical care and social services
Provides education to clients about referral sources and community agencies as needed. Advocates for client and community to bring to awareness the maintenance, improvement and development of needed services
Provides cultural mediation between communities and health and human services system where appropriate
Empowers individuals to access appropriate prevention and wellness services to develop their own self care
Maintains accurate client records including documentation of all contacts, services provided and outcomes
Develops and maintains strong working relationships with referral sources and community agencies
Attends department and inter-disciplinary team meetings and in-services and consults with leadership on a weekly basis or more frequently as needed. Meets regularly with other members of the team in the home SCFC clinic/medical home assigned.
Identifies potential clients through referrals from multiple sources, including but not limited to: Emergency Department or hospital admissions, patients identified by risk stratification tools used in the clinic, local social services agencies, CCO’s and private or family referral through the SCHS MH/Team Care.
Participates in community meetings and events with other agencies and organizations regarding community needs, attends continuing education classes and reports information and/or trains peer CHW’s. Coordinates community trainings, in-services, and networking opportunities for CHW’s.
Conducts all activities with the highest standards of professionalism and confidentiality. Complies with all applicable laws, regulations, policies and procedures, supporting the health system’s corporate integrity efforts by acting in an ethical and appropriate manner, reporting known or suspected violations of applicable rules, and cooperating fully with all company investigations and proceedings.
Delivers customer service and/or patient care in a manner that promotes goodwill, is timely, efficient and accurate
High school diploma or GED preferred (equivalent education and experience will be considered)
Additional training or education in related field preferred
Valid Oregon driver’s license and ability to meet SCHS driving requirements required
Ability to travel to meet with clients/attend business functions/trainings/meetings and all SCHS worksites required
Licensure/Certification/Registration: State workgroup in process of developing certification course. Certification may be required once courses and certification are implemented and available.
Personal Protective Equipment:
Must be able to wear appropriate Personal Protective Equipment (PPE) required to perform the job safely
Minimum 1 year in an advocate role for a community health services position preferred
Bilingual English/Spanish preferred
Must have excellent communication skills and ability to interact with a diverse population and professionally represent SCHS.
Strong team working and collaborative skills
Ability to effectively reach consensus with a diverse population with differing needs.
Ability to multi-task and work independtly
Attention to detail
Excellent organizational skills, written and oral communication and customer service skills, particularly in dealing with stressful personal interactions
Demonstrated ability and experience in computer applications, specifically MS Office
Some basic knowledge of the community being served and its residents, resources and problems
Understanding of federal, state, and local programs and their eligibility requirements and application processes,
principles and practices of Case Management; health and social service systems through outreach and maintenance of partner relationships
Ability to be pro-active in asking for help with multiple clients and organizations-churches/shelters