Community Health Worker

<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.

<b>Accountabilities</b>

• 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

Minimum Requirements

<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>