Lead Community Health Worker (CHW)

Job Summary

 

The Lead CHW goes beyond Medicine through accountability for building relationships and engaging our new members including locating, supporting with social services, educating on AbsoluteCare services, and enrolling into programs. The role is responsible for establishing trust and building meaningful relationships with AbsoluteCare members and communities. This role meets members where they are, including in the home, community, hospital, or office setting. Outreach includes telephonic and in-person. Additionally, this role will serve coaching and support for all center and community- based peers, and support the Manager in KPI management, reviews, outcomes, and miscellaneous tasks that support the team function.

 

This role is a core member of the interdisciplinary care team (ICT), focused on building trust with members and supporting improved engagement in their medical, social and behavioral health care through promoting compliance with treatment plans.  This involves locating members who have been lost to care or unable to telephonically reach for scheduling hospital/emergency department follow up visits, providing peer support to members in the community setting and connecting members to community resources to meet social determinants of health (SDOH) needs. The CHW primarily interfaces with members in the community setting, including meeting members in their home or community location.

 

The Lead CHW is knowledgeable of community resources and acts as a liaison between members and resources and helps members complete applications to necessary community-based and in-center services. This role establishes and maintains a trusting rapport with members, families, and relevant stakeholders for a specific assignment or for an estimated 3-6 month timeframe, as indicated, and based on the reason for referral.  

 

This role is key to member success in re-engaging in health care through building in-person relationships with members in their home setting, community locations, accompanying to specialist/PCP office visits and other individual community support. The Lead CHW documents all interactions in the electronic health record, attends team meetings, and serves as a community-based liaison for communication between the member and multidisciplinary team.

 

Key performance indicators of this role include successful engagement with members, member adherence in care (e.g., attending PCP and behavioral health appointments), closing social determinants of health (SDOH) gaps, and overall reduction in member hospital utilization.

 

 

Duties and Responsibilities

• Support and educate CHW peers on policies, workflows and procedures that are part of the daily operational function of a CHW team member.
• Monitor and impact Key performance indicators and outcomes that reflect the work of the team.
• Manage an active caseload, consistently meeting and ideally exceeding KPIs and performance expectations
• Assist Manager with various tasks, reporting and projects as needed that enhance or improve CHW team productivity or workflows.
• Conduct research and in-person outreach to locate difficult-to-contact enrollees to increase assessment completion and participation in clinical programs. 
• Conduct in-person non-clinical assessments to understand enrollee care needs, preferences, and socioeconomic barriers, and evaluate the home environment as needed, 
• Promote appropriate utilization of the health care system and AbsoluteCare services to reduce unnecessary ED or hospital admissions.
• Participate in the interdisciplinary care team (ICT) including case consultations, rounds, and follow up.
• Facilitate member enrollment in AbsoluteCare PCP, behavioral health and/or community care management programs
• Support the member to improve their wellbeing
• As needed, help the member engage with mental health and substance use treatment 
• Support the member to ensure pick-up of their prescriptions 
• Provide member education on community resources and benefits 
• Partner with care team (community, providers, internal staff) 
• Effectively build trust and rapport with members and their support systems and communities to drive engagement.  
• Effectively tell the story of AbsoluteCare, its services, benefits and how they can help the specific member being engaged.