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Job ID: 152501
Work Type: FT
Location: Philadelphia, PA, United States
Date Posted: Sep 12, 2022
Work Schedule: WILL REQUIRE full or partial on site work
DescriptionPenn Medicine is dedicated to our tripartite mission of providing the highest level of care to patients, conducting innovative research, and educating future leaders in the field of medicine. Working for this leading academic medical center means collaboration with top clinical, technical and business professionals across all disciplines.
<b> Community Health Workers (CHWs) </b> work one-on-one with high-risk patients to set and achieve health goals. Responsibilities include the identification and setting of health goals and follow-up provision of social support, health system navigation, community resource linkage and behavior change counseling. This is an autonomous position which requires a consistent drive for excellence, ability to make appropriate and timely decisions with minimal supervision, and effective problem-solving skills. CHWs are responsible for thorough and accurate documentation and working collaboratively within a multidisciplinary patient care team.
• Manage a caseload of 50-100 patients/year and achieve established benchmarks for patient care, including:
• Contacting 100% of patients each week
• Resolving at least 60% of patient goals
• Receiving a perfect satisfaction rating (10 of 10 in the Net Promoter Score) from at least 90% of patients
• Ensuring at least 60% of hospitalized patients attend post-hospital primary care follow-up within two weeks of discharge
• Ensuring at least 55% of outpatients achieve the chronic disease management goal they set with their physician
• Meet patients in hospitals/ primary care clinics and conduct open-ended needs assessment to understand broadly what patients’ goals are for their health. Use motivational interviewing to help patients create action plans for reaching their health goals. Provide a wide variety of support (including emotional support, referral to community based resources, social services, clinical services, etc.) based on CHW discretion and available resources. Examples include:
• Resolving social issues like homelessness, substance abuse and hunger
• Assisting patients with organizing their records, making follow‐up appointments, and ensuring their prescriptions are filled
• Coaching patients on how to get the most out of their doctor visits
• Helping patients fill out applications for Medical Assistance and SNAP (Supplemental Nutrition Assistance Program)
• Make weekly contact (follow‐up calls and/or home visits) to patients.
• Coordinate and communicate with clinical care teams to provide relevant information about patient’s goals, clinical emergencies, and patient concerns, and to obtain medical information needed to inform CHW’s work.
• Co-facilitate a weekly support group for patients.
• Work with other CHWs and staff to create a directory of community resources (e.g. foodbanks, housing assistance programs, childcare resources, etc.) in West and Southwest Philadelphia.
• Document each patient encounter in detail.
• Performs duties in accordance with Penn Medicine and entity values, policies, and procedures
• Other duties as assigned to support the unit, department, entity, and health system organization
<b>Required Education and Experience</b>
· H.S. Diploma/GED
· Long-time resident of West or Southwest Philadelphia and good knowledge of the resources of these communities
· Comfortable with home visits and outreach
· Prior experience as an outreach worker
<b> Licenses, Registrations, and Certifications </b>
· IMPACT Community Health Worker Training Certification for completion of training provided upon hiring.
<b>Required Skills and Abilities</b>
· Ability to exercise good judgment with patients and others involved in the delivery of the IMPaCT intervention
· Ability to carry out written and oral instructions
· Excellent oral and written communication skills
· Proficient in MS Word and computer data entry
<b>As part of our COVID-19 response, this position may currently be offering partial or full remote work. However, in the near future this position will require full or partial on-site work.</b>
We are an Equal Opportunity and Affirmative Action employer. Candidates are considered for employment without regard to race, ethnicity, color, sex, sexual orientation, gender identity, religion, national origin, ancestry, age, disability, marital status, familial status, genetic information, domestic or sexual violence victim status, citizenship status, military status, status as a protected veteran or any other status protected by applicable law.