Community Health Worker/population Health - New York, United States - Community Healthcare Network Inc
Description
The Population Health Community Health Worker will provide short term care coordination for patients being discharged from hospitals or other inpatient settings back to the community to ensure a successful transition and reduce the likelihood of avoidable readmission to the hospital.
The CHW-PH will connect patients to healthcare and social services to address their complex medical and social needs to improve overall health and wellbeing.
This is a hybrid role with a mix of field-based work and remote work, as directed.JOB FUNCTION:
Responsibilities include, but are not limited to:
- Extract data from internal and external data platforms to compile patient outreach lists, as directed.
- Conduct outreach to patients using multiple modes of communication, i.e., telephone, texting, video, and inperson.
- Assess patients' appropriateness for CHW services, educate patients on the services, and enroll patients into the program when interested.
- Coordinate discharge planning with hospital clinical and social work staff.
- Complete patient assessments at program enrollment using structured interview tools, motivational interviewing techniques, and traumainformed practices.
- Develop and maintain care plans in collaboration with patients using SMART goals.
- Participate in care conferences with the care team regarding the provision and coordination of services.
- Conduct regular visits with patients to assess new needs, discuss the status of SMART goals and update care plans.
- Work with the patients to provide health education, reconcile medications, monitor treatment adherence, assist with appointments, and assist with patient care plan tasks, as appropriate.
- Escort patients to internal and external healthcare or supportive service appointments in the community, as needed.
- Ensure patients are up to date on preventative healthcare services and screenings.
- Maintain consistent communication with patients and care team members.
- Respond to patient and provider inquiries within 1 business day and other inquiries within two (2) business days.
- Maintain care records including documentation of outreach and visit notes, assessments, care plans, care conferences, relevant external patient records, and release of information forms.
- Review individual clinical records for presence of adequate and required documentation, using chart review tools
- Participate in relevant internal and external training.
- Participate in Population Health team meetings, as assigned.
- Participate in supervision, as assigned.
- Perform other related duties as assigned.
WHAT WE LOOK FOR:
- High School diploma or its satisfactory equivalent.
- Minimum of two (2) years of employment experience, healthcare and/or care management related experience preferred.
- Bilingual Spanish preferred.
- Ability to work collaboratively and in a fastpaced environment.
- Excellent communication and problemsolving skills.
- Respect for the rights of individuals to make their own decisions about family planning, etc.
- Ability to communicate easily and display a cordial manner towards individuals from a variety of socioeconomic, cultural, and religious backgrounds.
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