The Community Health Workers (CHW) are trusted members of their community who help address chronic conditions, preventive health care needs, and health-related social needs. CHW’s have the skills and experience to understand what at-risk or vulnerable patients are going through and help them get through difficult times. CHW’s act as lead care managers to help patients address the social, medical and community problems that lead to poor health. The goal is to help patients address real-life obstacles (e.g. social drivers of health) that keep them from staying healthy, by supporting them with health care navigation, specialty appointments/referrals, PCP appointments/establishing routine care and preventative health screenings, cultural broker, financial services, and provide culturally appropriate health information on topics related to chronic disease management/prevention.

CalFresh program

Unemployment

Social Security Card

Jobs

Meals on wheels

Altamed Gives

Housing and utility assistance

Government phones

CalWORKs

Disability

• Assess patient and home environment to identify physical, social, and emotional and knowledge barriers to optimal health. Identify important information and relay to care team.
• Contribute to the development of individualized care plan by using evidence-based guidelines for patients
• Provide ongoing in-person or telephonic visits with patients to identify additional barriers to accessing care, and supporting the patient’s tailored plan of care.
• Facilitate patient’s health through advocacy, support with understanding and use of benefits, assistance in scheduling appointments, development of a support system, and reinforcement of self-management and organizational tools.
• Support patient’s well-being by using strong observation and communication skills to coordinate care between patients, and caregiver as well as community resources. Includes addressing social issues like homelessness, substance abuse, and hunger
• Assist patients in taking an active role in health management and promotion through coaching education navigation and referrals to appropriate care and community based resources. Includes assisting patients with the following: organizing their records, making follow-up appointments, filling prescriptions, completing applications for benefits like insurance and food stamps
• Complete timely and accurate documentation in Electronic Medical Records System to record assessment, observations, care plan, progress notes and all patient encounters
• Attend regular team meetings and interface and collaborate with diverse group of health care professionals and outside community resources to coordinate referrals and patient care, structuring effective communication mechanisms
• Utilize department desktop procedures, workflows, job aids and training material. Identifies barriers to work processes and brings to the attention of the manager.
• Adhere to all quality, safety protocols, compliance and regulatory standards to achieve program and patient desired outcomes. 11. Perform other duties assigned.
• Engaging highly complex patients, that requires traveling (to, but not limited to hospital/home/community/clinic) and meeting patient where they reside or socialize.
• Conduct comprehensive assessment to identify & address social factors affecting their health. Close connection and communication with Case Management/MSO team.
• Create and fully manage patients’ care plan based off of comprehensive assessment and patient’s input. Will participate in the case closure of patient finishing CHW program.
• Reports patient’s progress and needs during Interdisciplinary Care Team meetings.
• Leads linkages to community and social services for their paneled patients.

• High School Diploma or GED is required.
• Minimum of 3 years of experience directly working in the health care environment or a community outreach setting.
• Bilingual (Spanish/English) or another secondary language required due to population being served.