MG Community Health Worker SDOH

SUMMARY:

Under the direction of the program Social Worker, the Community Health Worker is a trusted member of the multi-disciplinary care management team who facilities the care of individuals with substance uses disorders (SUD) and Social Determinants of Health (SDOH) needs post Emergency Department discharge to promote adherence to key components of their health care. The community health worker engages patients, creates a trusting relationship, assists patients in navigating the health care system, makes patient visits in the home, community, Emergency Department, hospital or other setting, sets health goals and closely communicates with providers and care team members.

KEY RESPONSIBILITIES:

• Outreach and Engagement: CHWs conduct outreach activities, such as home visits, to connect with community members and assess their needs. 
• Care Coordination: They help individuals navigate complex healthcare and social service systems, coordinating care among different providers. 
• Resource Linkage: CHWs connect individuals with resources like housing, food, transportation, financial assistance, and other social services. 
• Health Education and Promotion: They provide culturally appropriate health information and education on topics like disease prevention, healthy lifestyles, and self-management of chronic conditions. 
• Advocacy: CHWs advocate for the needs of individuals and the community, ensuring they have access to needed services and resources. 
• Building Trust: CHWs build strong relationships within the community, fostering trust and understanding. 
• Providing Support: They offer informal counseling, social support, and coaching to help individuals adopt healthy behaviors and manage their health. 
• Community Education: CHWs organize and facilitate community events, workshops, and support groups to promote health and well-being. 
• Data Collection: They collect data on health concerns and needs within the community, reporting findings to healthcare providers and public health officials. 
• Health Screenings: CHWs may conduct basic health screenings like blood pressure checks and refer individuals for further testing or treatment. 
• Interpretation and Translation: CHWs may provide interpretation and translation services to facilitate communication between healthcare providers and patients. 
• Advocacy within the Healthcare System: They advocate for policies and systems changes that improve health equity and access to care. 
• Documentation and Reporting: CHWs maintain accurate records of their interactions with individuals and communities, reporting on their activities and outcomes. 
• Provides community health worker services to high-risk patients that have substance use disorders (SUD) and Social Determinants of Health (SDOH) needs
• Initiates face to face contact with high-risk patients in the Emergency Department, hospital, community, or home (via EMS visit and/or standalone visit) and conducts telephonic outreach on an as needed basis
• Reviews eligibility screening, psychosocial assessment and patient centered care plan developed by the Social Worker and adheres to treatment recommendations of the SW
• Works with the patient, family/caregiver provider and other care team members such as Physician, Social Worker, community-based NP/PA, MAT Provider, as appropriate, local EMS, PCP, BH Providers, etc. to set goals for patient's care, identify any barriers to care, and motivate patients to achieve those goals.
• Teaches key educational messages in person and over the phone and utilizes teach back methods to measure and ensure patients understanding
• Clearly documents all activities in the patient record
• Records and monitors the participants' progress toward goals within specific timeframes
• Assists patients with organizing their records, making follow-up appointments, and filling their prescriptions.
• Helps patients fill out applications, for example for Medical Assistance and SNAP (Supplemental Nutrition Assistance Program)
• Provides advocacy, patient education and support in accessing community-based and hospital-based programs
• Refers to internal or external services when appropriate
• Maintain regular communication with the patient
• Demonstrates cultural sensitivity and respect for the patient
• Prepares reports and documents as needed or requested
• Follows standards of work and consistently maintains department established caseloads and timeframes for case completion. Participates in the refinement of and development of new standards of work.
• Meets regularly 1:1 with the Director of Behavioral Health to review caseload and discuss barriers/challenges and review performance compared to current targets/expectations.
• Documents and reports all quality and patient safety events by recording and adhering to all of Brown University Health's safety reporting guidelines.
• Performs all job functions in compliance with applicable federal, state, local and company policies and procedures.
• Ability to travel to attend meetings with patients, PCPs and other members of the care team
• Attend staff meetings and education offerings both in person and via teleconference as required.
• CHW is considered a resource expert in the assigned community/region
• Performs other duties as assigned

REQUIRED QUALIFICATIONS:

• Minimum of 3 years healthcare, public health, or community-based experience
• Current unrestricted Driver's License
• MS Office Suite
• Possess basic knowledge of healthcare system and resources available in their geographical region
• Experience working with disadvantaged populations, SU populations and those impacted by social service needs
• Understanding of language, culture and socioeconomic circumstances and desire to work with diverse population. Knowledge of the impact of culture on health, illness, health practices, health beliefs, access to care and participation in treatment and services. Demonstrated oral and written communication skills and is comfortable working with individuals from cultural and linguistically different backgrounds who face barriers in obtaining care and support services.
• Ability to serve on a multi-disciplinary care team and update team members on important clinical important and/or barriers to patient reaching health care goals
• Understanding of how to advocate and work with patients so that he/she is in the best position to determine what they want and need, promoting the persons' right and capacity to make decisions themselves as well as encouraging and teaching patient self-confidence that will enable them to become self-advocates
• Knowledge of key principles of working with patients with disabilities - self-determination, self-advocacy and person/ family centered individual planning that allow persons with disabilities to live in the safest and least restrictive community-based setting.
• Understanding and respect for disability culture and barriers that prevent individuals from receiving appropriate and quality care. Dependable and responsible. Open minded, committed and respectful of our members with chronic/complex illness and or disabilities.
• Highly motivated and capable of self-directed
• Outstanding interpersonal skills of foremost importance to interact with families and patients.
• Exceptional organizational skills: ability to multi-task and work independently and as part of a team
• Demonstrated ability to prioritize, multitask, and work in a rapidly changing environment with multiple demands.
• Ability to utilize tools for the effective documentation of the care management process.

EDUCATION:

High school diploma required. Bachelor's degree preferred

PHYSICAL REQUIREMENTS AND MENTAL DEMANDS

A combination of physical and mental abilities to effectively serve their communities. Physically, they need to be able to stand for extended periods, navigate diverse environments, and potentially lift or carry light objects. Mentally, strong communication, empathy, and problem-solving skills are crucial for building trust and facilitating access to healthcare and social services.

Brown University Health is an Equal Opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, age, ethnicity, sexual orientation, ancestry, genetics, gender identity or expression, disability, protected veteran, or marital status. Brown University Health is a VEVRAA Federal Contractor.

Location: BHMG-North Dartmouth-531 Faunce Comer Rd, USA: MA: North Dartmouth

Work Type: Full Time

Shift: Shift 1

Union: Non-Union