Community Health Worker - Trinity, Florida

Community Health Worker - Trinity, Florida

A TEAM OF DIFFERENCE MAKERS:

At Author Heath, we are dedicated to a field-based, home-based care model, ensuring we meet our members right where they are, in their homes, and their communities. We are seeking professionals who are willing to go the extra mile to connect with our members in a high-tech environment where we are there at all times assisting the members. We value non-judgmental, respectful, and empathetic interactions, aiming to meet the unique needs of each member. Immerse yourself in the realm of specialized care at Author Health. Our primary mission is to deliver outstanding care for seniors battling with serious mental illnesses (SMIs) and substance use disorders (SUDs). We are committed to making a significant impact in the lives of our most vulnerable population. With our advanced technology, our members can enjoy a stress-free experience as we provide all the necessary services. Join us in our mission to revolutionize healthcare.

We seek a community health worker (CHW) to form relationships with patients and their caregivers and improve their health and general well-being through education, care coordination, connection to community-based resources, and technology facilitation. Central to this role is to increase patients’ stability and well-being in the community by fostering adherence to outpatient care and addressing social needs and drivers of utilization thereby eliminating avoidable use of the emergency department and hospital setting. 

We aim to generate a coordinated and high-functioning health care ecosystem to support seniors with serious mental illness and substance use disorders. 

 

WHAT WE ARE SEARCHING FOR:

 

Community Health Worker:

Meet patients in their homes, other community settings, or telephonically/virtually  forming trusting relationships to help clarify and achieve health goals as per patients’ individualized care plans

• Help ensure that patients attend Author Health and other healthcare appointments; identify and remove barriers to engagement with necessary resources and supports
• Ensure patients have timely follow up with Author Health provider(s) and CHW, as well as Primary Care Provider, following an Emergency Department (ED) or inpatient hospitalization (IH)
• Maintain contact with all patients on assigned patient panel, as prescribed in patients’ care plans, escalating any newly identified risks or patient caregiver needs to the appropriate team member and complete documentation
• Assess and identify patients’ drivers of ED/IH utilization and work collaboratively with patients’ to reduce avoidable ED/IH utilization, including, but not limited to, development of, and adherence to, a hospital avoidance plan 

Assess patients’ social determinants of health (SDOH) needs and assist with connection to community-based organizations and agencies to alleviate those needs identified or escalate to the appropriate team member to ensure SDOH needs are met

• Assist patients’/caregivers’ in interpreting healthcare information, instructions and guidance to increase health literacy and improve population health, i.e, provide patient education on chronic disease management

Serve a crucial function on a multidisciplinary team that includes psychiatrists, nurse practitioners, social workers, and health navigators; participate in huddles and multidisciplinary communication Provide support and advocacy to patients and their caregivers

• As needed, facilitate communication between providers and their patients including  facilitating patients’ use of technology to conduct virtual visits with other providers on the team

 

WHAT IS YOUR SUPER POWER? 

• Passionate about working, have experience with, serving patients with behavioral and medical conditions who may historically have difficulty navigating the healthcare system and by default, rely on hospital care
• Able to think critically about patients’/caregivers’ drivers of utilization and provide input for, and implement on, individualized care plans with a focus on reducing avoidable ED/IH visits
• Attentive to detail and focused on documenting care interventions for patients
• Skilled interpersonally and possess the ability to work effectively with a wide range of constituencies in a diverse community
• Comfortable communicating medical information to health care professionals, care coordinators, and patients
• Knowledgeable of community agencies and resources with knowledge of multi-system outreach programs related to health care delivery
• Able to organiz