Community Health Worker - New York, United States - RONALD MCDONALD HOUSE NEW YORK

Description

• The Community Health Worker will participate in and support the interdisciplinary care team efforts in the prevention and control of chronic diseases by providing patients/caregivers with selfmanagement education and support
• Identify and communicate barriers to achievement of disease selfmanagement and facilitate their removal
• The Community Health Worker provides education and advocacy and evaluates patients' eligibility for social service programs.
• The Community Health Workers alerts members of the care team when followup is required and ensures efficient and successful access and linkage to the full array of physical and behavioral health services
• Assist and conduct various research projects in accordance with the organization's needs and mission

• Develop an effective and efficient interpersonal and trusting relationship with patients/caregivers while maintaining a supportive coaching environment.
• Provide education and social support to patients and their family members.
• Provide emotional support by showing interest and compassion. Report to professional team members any concern in order to ensure care plan revision as appropriate.
• Provide continuity and promotes trust. Act as patient advocate responding to and working to resolve patient concerns or barriers.

• Reinforce and review the plan of care with the patient
• Call patients at intervals as per established plan of care to check on their progress, including making sure they have kept any scheduled medical or other appointments

• Work with patients to establish health improvement plans and set personalized goals and supports patients in achieving those goals.
• Employ behavior change facilitation skills such as motivational interviewing, to assess readiness, health goal setting short and/or longterm needs, engage patient's plans for change following the established plan of care.
• Conduct home and telephone visits and provides coaching to patients/caregivers around their behavior changes to improve health status, reduce health risks and improve quality of life.
• Assist with identifying patients' barriers to selfcare and the additional services patients may need, such as home health care, caregiver support, referral to various entitlements and resources.
• Help patients by reinforcing use of existing selfmanagement skills and promotes the development of new skills to enhance success. Empower patients with skills to provide enhanced interaction with their health care provider. Provide cultural and language adaptation as needed.
• Foster an environment of individual responsibility. Help patients take ownership of their health care by having patients set their own personal health goals.
• Teach coping skills.
• Assist patient with selfmonitoring activities.
• Promote active participation by the patient in his/her health care by encouraging patient communication of selfmonitoring results to the patient's primary health care provider.

• Maintain accurate patient records by documenting all contacts (successful and attempts),, services provided, and outcomes in order to track all clients and services for future reference.
• Track client information, schedules, files, and forms in a HIPAA compliant manner.
• Participates in program's performance improvement activities. Provides suggestions for improvements and enhancements to the Community Health Worker program and interventions based on data/experience.
• Community canvassing and building strong partnerships
• Conducting social risk assessments, and developing tools for data collection and evaluation
• Documents interactions and interventions as directed.
• Performs other related duties incidental to the work described herein.

• Support the preliminary plan of care with the patient
• Understand patient and family's goals, behavioral motivation, and readiness
• Identify needed services
• Screen clients for eligibility for direct and support services
• Obtain input and signoff from the Care Coordinator
• Update plan of care as needed.
• Depending on the level of need identified in the assessment, the Community Health Worker will need to do more than provide information, their role is to coordinate the referral (call the provider, make the appointment on behalf of the patient, and ensure the patient gets to their appointment)

• High School Diploma equivalent required. Associate's or Bachelor's degree in a human services or related field preferred.
• Bilingual skills preferred
• Preferred **Minimum of 1year experience in care coordination, community health, social service, or medical pract