Community Health Worker - Senior Citizen's Center

Job Purpose & Position Overview
The purpose of this position is to provide culturally responsive outreach, education, care coordination, and support services for community members in need of chronic disease and long care support. The Community Health Worker will serve as a bridge between community members, healthcare providers, and community resources to improve health outcomes and reduce health disparities.
Specific Job Duties/Responsibilities:
• Demonstrate the Public Health Department's core mission, vision and values
• Home visit assigned clients as scheduled by Senior Citizen’s Center Director.
• Assist with medication needs and translation.
• Provide transportation to and from Twelve Clans Unity Hospital and WPHD Programs.
• Provide supervised home health care for assigned clients, and will include:
• Blood pressure/blood glucose monitoring.
• Provide medication education.
• Educate on healthy lifestyle habits.
• Refer to resources as necessary for any Indigenous Social Determinants of Health
• Maintain records and reports as necessary to supervisor.
• Follow-up on at-risk community members.
• Notify patients of scheduled doctor appointments.
• Follow-up from internal staff and referred provider appointments.
• Assist with infections disease screenings.
• Attend all in-service and classes that are health related when possible.
• Attend mandatory training.
• Prepare monthly reports and submit to supervisor.
• Complete patient charting in a timely manner.
• Responsible for maintaining GSA vehicles at all times.
SPECIALTY AREA – SENIOR CITIZEN'S CENTER COMMUNITY HEALTH WORKER
• Conduct home visits and community outreach with elders and older adults to support healthy aging, independence, and overall wellness.
• Assist elders with accessing healthcare services, medications, transportation, food assistance, housing resources, and other supportive services.
• Support medication management activities, including medication reminders, medication education, identifying barriers to medication adherence, and reporting concerns to the appropriate healthcare providers.
• Conduct wellness check-ins with elders and their caregivers to monitor health status, social needs, safety concerns, and access to services.
• Assist elders with scheduling, attending, and following up on primary care, specialty care, behavioral health, dental, vision, and other healthcare appointments.
• Provide transportation support to medical appointments, Senior Center activities, community events, cultural activities, and other approved services.
• Conduct follow-up visits and phone calls following hospitalizations, emergency department visits, rehabilitation stays, nursing facility admissions, and specialty care appointments.
• Assist with chronic disease self-management support for elders living with diabetes, hypertension, cardiovascular disease, arthritis, respiratory disease, dementia, and other chronic health conditions.
• Promote healthy lifestyle practices, including nutrition, physical activity, fall prevention, medication safety, sleep hygiene, and social engagement.
• Assist with home safety assessments and identify potential risks related to falls, mobility limitations, environmental hazards, and access to basic needs.
• Support elders in maintaining independence by connecting them with community resources, caregiver supports, home services, and benefits programs.
• Provide education regarding aging-related health issues, caregiver resources, elder rights, dementia awareness, advanced care planning, and available community supports.
• Identify and address barriers related to Indigenous Social Determinants of Health, including transportation, food security, housing, healthcare access, financial concerns, and social isolation.
• Support caregiver wellness by providing information, referrals, and connections to respite and support services.
• Assist with Senior Center programming, wellness activities, educational events, cultural activities, exercise programs, congregate meals, and community outreach efforts.
• Promote social connectedness and reduce isolation through regular contact, engagement opportunities, cultural participation, and community involvement.
• Coordinate referrals to healthcare providers, social service agencies, elder services programs, and community resources.
• Maintain accurate documentation, client records, encounter notes, and monthly reports in accordance with departmental policies.
• Participate in multidisciplinary care team meetings, quality improvement activities, and program evaluation efforts.
• Promote culturally grounded, trauma-informed, elder-centered, and strengths-based approaches to care while supporting Indigen