Director, Patient Centered Services and Outreach and Co-Dir Patient and Comm Engag

Description

POSITION SUMMARY

Our Community Health Workers (CHWs) are strong patient advocates. Building trust with our patients, their families and our community and bringing an encouraging spirit to the position are two keys to being a successful Community Health Worker.  CHWs support our mission by creating community outreach programs and activities that are designed to promote, maintain and improve the health of the patients and families we serve. Given the CHWs’ necessary interactions with patients, families, staff, providers, residents/fellows, social service agencies and other Community Based Organizations, private, state and federal insurance programs, and others, excellent communication skills are an absolutely necessary characteristic for effective CHWs. 

As a CHW, the Director is responsible for leading the Community Health Workers (CHWs) and responsible for the oversight and coordination of patient centered services in the areas of medical case and care management, lifestyle and nutrition services as well as geriatric and Alzheimers and Dementia services. This position leads various patient-, community- and family-centered activities on behalf of The Wright Center entities (collectively, “TWC”), and liaises regularly with the volunteer Directors on TWCPCE as well as TWCCH. An important addition to the Care and Case Management (C/CM) Department, this position works closely with the C/CM team as well as the Director of Community Outreach and Engagement (CO&E) and the Board of Directors of TWCPCE in developing, organizing and implementing patient- and family-centered care improvement and wellness initiatives, capturing all clinically billable activities and properly documenting those activities to promote stewardship of resources.  This position also supports the work of TWC in its commitment to continuously develop and enhance TWCGME’s population health curriculum to ensure that America’s physician workforce is community-competent as well as compassionate. 

To force multiply the impact of this role, the Director Patient Centered Services & Outreach and Co-Director PCE also serves in a volunteer capacity as one of three Co-Directors of TWCPCE (in partnership with the Community Outreach & Engagement Director and Director of Patient Engagement & Behavioral Health Outreach). Affiliated with TWCCH, TWCPCE is a tax-exempt, Pennsylvania non-profit organization established to support the education of, advocacy for and empowerment of patients and families. This position will engage and organize patients and families, staff and residents, and the community to increase levels of engagement across the board to improve health outcomes.

ESSENTIAL JOB DUTIES and FUNCTIONS

While living and demonstrating our Core Values, this position will:

Community Health Worker

• Takes direction from and works closely with the AVP, Integrated Primary Health and the C/CM team in addressing patients’ needs as they relate to Geriatrics/A & D, Lifestyle and Nutrition, and primary care service
• Helps patients identify social and economic issues that affect their overall health and develops responsive health/social management plans and goals
• Educates patients on the proper use of the Emergency Department and provides information for alternatives by coaching patients in the effective management of their chronic health conditions and self-care
• Assists patient in understanding care plans and instructions
• Motivates patients to be active and engaged participants in their health and overall wellbeing
• Provides support and advocacy during initial medical visits or when necessary to assure patients’ medical needs are met and necessary referrals are activated
• Follows up with both patients and providers regarding health/social services plans  
• Travels to regional hospitals as needed or as requested to support patient needs
• Continuously works to expand knowledge and understanding of community resources and services available to our patients and their families
• Facilitates patient access to community resources, including locating housing, food, clothing, prenatal classes, parenting, and relevant mental health services
• Assists patients in utilizing community services, including scheduling appointments with social services agencies and assisting with completion of applications for programs for which they may be eligible
• Facilitates communication and coordination of services between providers and the patients
• Coordinates and monitors services, including comprehensive tracking of patients’ compliance in relation to care plan objectives
• Works to reduce cultural and socio-economic barriers between patients and institutions
• Responsible for oversight of remote patient mo