Community Health Worker

Description

Community Health Worker (CHW) will with specific target populations on identifying and address Social Determinants of Health (SDoH). CHWs will work closely with medical providers, primary care teams, and other agencies to improve patient care and outcomes. 

Under the direction of the Nursing Leadership, Care Coordination Nurse Manger, and the Nurse Care Coordinators, the CHW will provide patient support and provide specialized and focused assistance and other duties as assigned at all Fenway Health clinical locations. 

Principal Duties and Responsibilities:

Care Coordination

• Support the Nurse Care Coordinators with care coordination requests 
• Provides coverage of care coordination duties as needed
• Assists patients with completion of paperwork
• Provide patients with updated and accurate information regarding care coordination services
• Actively build good working relationships with clients and colleagues
• Assists patients with applications for enrollment in programs as needed
• Document in EHR for each patient interaction
• Assists department with care coordination administrative tasks such as completing and faxing client paperwork
• Assist with outgoing phone calls to community resources as needed
• Assists with distributing program materials to clients via mail as needed
• Convey the purposes and services of a program to the patient population and the impact that program or service would have 
• Help patients develop health management plans and goals 
• Follow-up with health management/care plans with both patients and providers 
• Coach patients in effective management of their chronic health conditions and self-care 
• Assist patient in understanding care plans and instructions 
• Document activities, service plans, and results in an effective manner while strictly adhering to the policies and procedures in place 
• Establish positive, supportive relationships with participants and provide feedback  
• Assist patients in accessing health related services, including but not limited to: obtaining a medical home, providing instruction on appropriate use of the medical home, overcoming barriers to obtaining needed medical care and social services 
• Facilitate communication and coordinate services between providers 
• Motivate patients to be active, engaged participants in their health 
• Build and maintain positive working relationships with the clients, providers, nurse case managers, agency representatives, supervisors and office staff 
• Continuously expand knowledge and understanding of community resources, services and programs provided; human relations and the procedures used in dealing with the public as part of a service or program; volunteer resources and the practices associated with using volunteers, operations, functions, policies and procedures associated with the department or program area, procedures and resources available to handle new, unusual or different situations 

Attends to healthcare issues of specific populations

• Provides age-specific, culturally responsive care per Fenway Community Health policy
• Works with the care team to complete processes so that patients may receive benefits such as durable medical equipment and medical leave approvals
• Conducts outreach and coordinates with medical case managers to mitigate barriers to engagement in care
• Provide high degree of customer service
• Outreach to patient to obtain necessary information related to case management needs
• Be sensitive to handling sensitive medical and behavioral health information

Provides health education

• Provides community health education
• Provides patient education related to their medical and psychosocial needs 
• Maintains comprehensive knowledge of vaccines, medications, and other therapeutic interventions as appropriate to our outpatient clinic
• Accesses Nursing Department resources to ensure patients are provided most up to date and evidence-based information 
• Maintains comprehensive knowledge of Fenway Health policies, procedures and services including those of TFI 
• Maintains knowledge of community resources
• Assists in training other employees in the medical department including orientation of new staff, volunteers, and students

Effectively communicates with patients, co-workers on medical team, in medical department and across departments

• Effectively work with people (staff, clients, doctors, agencies, etc) from diverse backgrounds in reducing cultural and socio-economic barriers between clients and institutions 
• Demonstrates competency in EMR, Microsoft Outlook, etc
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