Population Health Specialist II

Job Description Summary

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Part of what makes a Community Health Worker such an effective member of a health care delivery team is the flexibility and diversity of what they can do within the clinic and in the community. There is a wide range of activities, tasks, and responsibilities a CHW (Community Health Worker) can take on in the healthcare setting.
The primary responsibilities of a CHW are to build trusting relationships with clients and to connect those clients to care, eliminating barriers and advocating for systemic changes along the way. The effectiveness of CHWs lies in their ability to gain access to hard-to-reach individuals and to patiently coach and support them as they work towards health care goals.

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How will you make an impact & Requirements

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Community Health Worker

The role of the CHW includes the following:

• Create connections between vulnerable populations and the health care system

CHWs in HCH programs work to guide patients experiencing homelessness toward more permanent primary care services outside the hospital system. Establishing a secure, trusted connection with a primary care provider can help prevent persons experiencing homelessness from reliance on Emergency Departments to meet primary care needs.

• Care coordination and care transitions for clients

The mobility of CHWs within their communities creates opportunities for more coordinated care. CHWs can serve as a liaison between multiple services and help with care coordination and care transitions for their clients. In the process of connecting clients with multiple services, CHWs build relationships with local agencies, advocating for their clients in the process. The more CHWs are involved in the community at large, the more effective the linkages between the community and the health care system become.

• Assist clients with enrollment in programs and benefits for which they are eligible

In addition to connecting clients with health care services, CHWs work to connect clients with various social service programs for which they may be eligible. These programs and benefits can range from enrollment into SSI/SSDI to enrollment into a GED program.

• Encourage cultural competence among health care professionals serving vulnerable populations

CHWs’ lived experience of homelessness helps them build rapport with clients while also informing policies, procedures, and practices within the HCH clinic. CHWs have a unique insight into the perspectives of their clients which helps them identify barriers or unmet needs within the HCH clinic that may go unnoticed by HCH clinicians or administrators.

• Advocate for vulnerable populations within the health care system and the community at large

CHWs amplify the voices of the community within their HCH clinics thereby informing health professionals of the evolving needs and conditions of their target population.

Duties:

Community health workers typically do the following:

• Coordinate care among individuals, communities, and health and social service systems
• Conduct outreach, such as through home visits
• Provide culturally appropriate health and informational resources
• Oversee case management and resource access
• Advocate for individuals and communities regarding housing, food security, and other needs
• Provide coaching and social support, such as nutrition training, recovery services for mental health and substance use disorders, and chronic disease management and prevention
• Provide services, such as basic health screenings and first aid

Community Health Workers work closely with other healthcare and social service providers, including Registered Nurses, Social Workers, Substance Abuse, Behavioral Health, and Mental Health Counselors.

Responsibilities:

Community Health Workers build trust and community capacity by improving the health and social welfare of the clients they serve. When a conflict arises among individuals, groups, agencies, or institutions, Community Health Workers should consider all issues and give priority to those that promote the wellness and quality of living for the individual/client. The following provisions promote the professional integrity of Community Health Workers.

• Honesty: Community Health Workers are professionals that strive to ensure the best health outcomes for the communities they serve. They communicate the potential benefits and consequences of available services, including the programs they are employed under.
• Confidentiality: Community Health Workers respect the confidentiality, privacy, and trust of individuals, families, and communities that they serve. They understand and abide by