Lead CHW Community Specialist PCCHW

Responsibilities:

• Patient care:
• • 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
• Leadership
• • Participate in leadership decisions within the organization, including hiring new staff, and providing input to strategic direction and prioritization for the Center’s work.
• • Lead an organizational project with a management mentor
• • Act as a spokesperson for IMPaCT, including but not limited to speaking to the media, presenting to community groups to raise the awareness of IMPaCT, and facilitating sessions of CHW and Manager training
• • Serve as role models and mentors to CHWs to support performance improvement
• • Conduct training on topics such as home visit safety, outreach principles, etc.
• • Work with Managers and Director to identify areas for improvement and makes recommendations to support staff development
• • Act as a mentor and support person for CHW, specifically by providing guidance, training and advice to new staff and through ongoing CHW professional development activities
• Community Engagement Specialist
• • Uses deep knowledge and understanding of the IMPaCT model and the needs of historically underserved patient communities to develop, implement and provide oversight of outreach and engagement strategies to close gaps in patient needs.
• • Co-leads and participates in expanded efforts to improve PCCHW’s community ties, the resource referral process, and the connection to programs and services that are responsive to and reflective of the needs and interests of patients
• • Co-leads and takes an equity approach by identifying local recruitment sites and partners (e.g., Philadelphia schools, places of worship, community hubs, etc.) within the community to assist with the recruiting and hiring of CHWs.
• • Act as a spokesperson and representative for PCCHW at community events and meetings with City organizations and community groups.
• • Mobilizes community/patients to address structures and systems that create inequity (e.g., voting, housing, a living wage, Social Determinants of Health).
• • Identify opportunities for PCCHW patients to share their lived experiences in a way that helps to amplify their voices and allows them to inform decision-making.
• • Participates in Penn Medicine-related initiatives as needed and ensure community voices, engagement, and feedback are incorporated and represented.
• • Stays current on community activities and events that could benefit our patients and recommends opportunities for PCCHW to participate.
• • Assists with identifying and creating CHW professional development curriculum by staying up to date on frequently used resources that address patient needs (e.g., PA Waiver Services, Motivcare, Community Behavioral Health).

Credentials:

Education or Equivalent Experience:

• H.S. Diploma/GED (Required)
• At least 5 years of experience as an IMPaCT CHW with a 3.4 rating on current evaluation Good knowledge of Philadelphia and resources available to support communities throughout the city Comfortable with home visits and outreach. Prior experience as an outreach worker a plus