Community Health Advocate

This program will require meeting patients and/or family members in the patients homes or other locations in the community.

The Continuing Care Community Health Worker is responsible for working in conjunction with an interdisciplinary team in order to improve patient social behavioral and mental health needs through outreach and engagement activities. Such activities include telephonic and written communication as well as in-person opportunities with patients providers team members and community-based organizations.

Work may be focused on but not limited to: 1) establishing effective relationships and guiding the patient/caregiver through the healthcare system working to eliminate barriers that might otherwise adversely impact patient care/outcomes; 2) providing general education/training designed to promote self-awareness and reinforce/maximize patient/caregiver self-management skills/tools/resources; and 3) facilitating access to support services community resources and primary care for enrolled patients and tools for self-management support.

Essential Key Job Responsibilities

Relationship Building:

• Establishes rapport with patient and caregivers evaluates patients level of health literacy and comprehension provides information/guidance for an effective care transition and follows up with the recipient to ensure that information is understood by the recipient.
• Responsible for building and maintaining a positive working relationship with providers community-based organizations social services and public health for example.
• Monitors effectiveness of services provided by external resources and provides timely feedback to the provider/interdisciplinary team.
• Acts as liaison with members and families to physicians staff community resources and others
• Acts as the liaison between the healthcare team and community resources may require meeting with community leaders to assist in the process of building and maintaining a working/business relationship between the team and community partner.

Patient Care:

• Acts as an advocate for the patient and family by locating appropriate community resources to address concerns and reduce risk of hospitalization or readmission.
• Coaches patient/caregiver to improve their communication with physicians nurses and other members of the healthcare system; assists patient/caregiver in setting tracking and meeting personal health goals.
• Collaborates on patient care issues with an interdisciplinary team participating in regular and ad hoc case review and Interdisciplinary Team Meetings and consults with the healthcare team before taking any action that requires a physician order or insurance authorization.
• Facilitates patient self-management skills around health status and problem solving for barriers to care.
• Meets and/or follows-up with patients via phone and/or clinic visit to coordinate and/or provide timely direct assistance in meeting the self-management goals identified.
• Monitor patient progress towards achievement of goals identified in the plan of care and provide ongoing status reports to the healthcare team escalate issues/barriers as identified.
• Model commitment to continuous quality improvement by engaging in quality improvement initiatives and projects such as identifying and addressing gaps and by identifying developing and testing new practices for improving the outcomes of Members.
• Assists with administration of social determinants of health screening activities as assigned.

Clerical:

• Ensures documentation is accurate useful and in compliance with company policy.
• Review interpret and escalate to care team data and/or information from multiple different electronic platforms.
• Data entry scheduling appointments and other related tasks.
• Assist patients / caregivers with completion of various forms and paperwork related to identified social need(s).
• Other duties as assigned.