Community Health Worker - Recuperative Care Center (RCC)

SUMMARY:

*Please note: This position is funded by the RIZE grant.* 

Grant Funded Positions**

**Employees hired for grant funded postions will be given priority for permanent opportunities.

The Community Health Worker (CHW) at the Lynn Community Health Center (LCHC) is part of an integrated and interdisciplinary care team working to address patients’ health needs, with an emphasis on substance use disorders.  The community health worker will provide culturally appropriate individual and group health education, coaching, informal counseling, case management, care coordination, and advocacy in order to promote, facilitate and improve access to ongoing primary and behavioral health care for members of the target population. The community health worker works with  interdisciplinary care teams and other providers, as appropriate to promote, maintain, and improve the patient’s health.

CHW  must have a deep understanding of and respect for each individual’s unique path in making sustainable and positive life change as it relates to SUD.  CHW must have knowledge and experience navigating the drug and alcohol treatment system, experience providing overdose prevention education and Narcan training. CHW must have experience with harm reduction techniques and be comfortable applying as needed.

The CHW will serve as an advocate and motivator to individuals with SUD.

The primary responsibility of the community health worker is to educate, advocate and coach patients who require additional support to meaningfully address medical, social, and psychological needs. The patient’s behavioral /primary  care provider takes the lead role in devising patient centered treatment or action plan(s) and identifying focus areas for the community health worker to work with the patient. The community health worker collaborates closely with the provider, nurse care manager, team nurse manager, and other members of the interdisciplinary care team. The community health worker works with the patient in clinic and community settings, as well as the patient’s home.

Additionally, the Community Health Worker participates in LCHC community outreach efforts, as appropriate and as assigned.  This may include participating in health screenings, health education programs or counseling at health fairs and other similar community events. The Community Health Worker also plays an important role in the community on behalf of patients to provide assistance with skill building, facilitating linkages with other community based and natural support systems, and advocating for community needs.

The community health worker reports to the Medical Outreach Program Manager.  The community health worker receives input and consultation on patient centered care plans from individual behavioral and primary care providers, team nurse manager, and  nurse care manager with whom (s)he shares patients.

 

HOURS OF WORK:

  • Occasional evening and weekend hours may be required.

DUTIES AND RESPONSIBILITIES:

  1. Work with the patient and interdisciplinary care team to identify, develop and implement a cultural competent and patient directed/centered individualized treatment/care plan.
  2. Assist patient to follow treatment recommendations of the interdisciplinary team, practice healthy behaviors and access necessary social, medical, behavioral support services and programs.
  3. Conduct outreach and engagement activities that support patient continuity of care, including re-engaging patients in care if they miss appointments and/or do not follow up on treatment.
  4. Conduct an initial and periodic needs assessments, including assessing barriers and assets (e.g. transportation, community bariers, social supports); patient and family or caregiver preferences; language, literacy and cultural preferences.
  5. Promote patient treatment adherence through assessing patient readiness to make changes, assisting patient in making changes in daily routines, identifying barriers and assisting patients with developing strategies to address barriers.
  6. Meet face-to-face with patients according to frequency agreed upon by patient, supervisor, and interdiciplinary care team. Provide other support and follow up via telephone or mail contact as necessary.
  7. Collaborate with other providers, staff and community resources to enhance coordination, quality and efficiency in care.
  8. Communicate all changes and concerns to the behavioral health/primary care provider, nurse manager, and nurse care manager with whom (s)he shares patients.
  9. Conduct home visits alone or in conjunction with member(s) of the interdisciplinary team  as appropriate and consistent with safety for the employee and patient.
  10. Provide  culturally competent support, individual and group education, guidance, mentoring, and coaching regarding chronic disease management, comprehensive preventive care and self management goals.
  11. Organize and or facilitate health education groups that promote wellness.
  12. Assist patients with effectively navigating health care and social service systems, including arranging for transportation and accompanying patients to appointments as requested by care team.
  13. Support patients in preparing questions for provider’s visit and assist patients in understanding care plans and instructions, and tailoring communications to appropriate health literacy level.
  14. Provide support for  chronic disease self-management to individuals and their families.
  15. Show initiative in working creatively with patients to address their identified needs and help them move towards successful resolution of challenges.
  16. Consult and seek support from members of the interdisciplinary care team to enhance knowledge and foster professional growth.
  17.  Provide culturally competent care coordination and support services for patients depending on individual needs and preferences.   These include but are not limited to:
  • link patients with resources and empower them to use them to their advantage
  • advocate for individual and community health needs for the patient
  • direct practical assistance, i.e. filling out  forms, making appointments as appropriate
  • coordinating interpreter services
  • escort patients to pharmacy; grocery store; food pantry and other community locations as needed to meet goals of treatment/care plan
  1. Network/collaborate with community leaders, area health providers, voluntary organizations and others who can contribute to ongoing assessment of the health needs of the target population.
  2. Conduct community outreach to:
  • provide information/make referrals to/coordinate needed services
  • identify community resources that provide needed support for patients
  • provide health education to individuals and groups on prevention and public health risks and problems
  • educate staff/providers about target population and community characteristics and needs
  1. Participate in meetings with supervisor and attend team and staff meetings at the health center.
  2. Participate in staff development trainings and external educational offerings to maintain and improve knowledge base.
  3. Accurately document all patient interactions in a timely fashion in the designated electronic health record. Documentation includes but not limited to: care plan progress,  telephone calls, home visits, time with providers, case management,  travel time etc.
  4. Keep logs, data on patient contacts, as required by funding source.

Requirements

QUALIFICATIONS:

  • Bachelor’s degree  in health sciences, social work, sociology, human services or related field preferred
  • Ability to work with and relate to individuals and families from diverse backgrounds and experiences
  • Strong knowledge of local community, social service, and cultural resources 
  • Strong organizational, interpersonal,  attention to detail, time management, multi-tasking, and problem solving skills 
  • History of good attendance and positive work attitude
  • Excellent communication skills and ability to set personal boundaries

EXPERIENCE AND TRAINING:

  • Completion of a 5 day training for Recovery Coaches through RIZE
  • Three or more years experience as a community health worker or case manager in a community health setting; and/or related experience in health/human services, social services or advocacy. 
  • Experience in outreach within mental health, community-based treatments or medical comorbidity.
  • Ability to openly address and acknowledge issues of addiction, substance use and mental illness.
  • Training and or certification as a community health worker preferred. Community health worker should obtain certification within one year of Massachusett’s Department of Health certification approval and or within six months of hire, whichever  comes first.
  •  Experience providing health education and knowledge of health promotion/wellness preferred.

Lynn Community Health Center (LCHC) provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to race, color, religion, sex, national origin, age, disability or genetics. In addition to federal law requirements, LCHC complies with applicable state and local laws governing nondiscrimination in employment in every location in which the company has facilities. This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, and transfer, leaves of absence, compensation and training. LCHC expressly prohibits any form of workplace harassment based on race, color, religion, gender, sexual orientation, gender identity or expression, national origin, age, genetic information, disability, or veteran status. Improper interference with the ability of LCHC’s employees to perform their job duties may result in discipline up to and including discharge. 

Job Posting ID: 19-013

Hours

Full-Time