Community Health Worker

• Complete Health Risk Assessments (HRA) in MHNConnect platform with patients who meet eligibility criteria (Chicago West side zip codes, are medically uninsured or have Medicaid)

• Assist with community resources and scheduling appointments

• Enroll eligible patients in disease management program(s) and provide disease specific and preventive care patient education according to program requirements. CHW may be responsible for one, two, or all three disease management programs: Diabetes, Hypertension, and Depression.

• Monitor patients (in person or by telephone) at required frequencies and track clinical outcomes such as PHQ-9, blood pressure, HbA1c. Use MHNConnect worklist to identify and re-engage patients who are not participating as expected in the disease management program.

• Support the treatment plan prescribed by PCPs, focusing on treatment adherence, side effects, other complications, and effectiveness of treatment.

• Facilitate treatment plan changes for patients who are not improving as expected in consultation with the PCP. These may include changes in medications, treatments, or appropriate referrals for clinically indicated services outside the primary care clinic (e.g., social services such as housing assistance, vocational rehabilitation, subspeciality, mental health specialty care, substance abuse treatment, etc.).

• Enroll patients (in person or by telephone) in Remote Management ("CAREMINDr" app-based) program for hypertension, diabetes, depression.

• Complete CAREMINDr monitoring duties within the CAREMINDr platform, outreaching patients with abnormal self-reported values per workflows.

• Prepare for and participate in regularly scheduled caseload oversight with the behavioral health specialist and/or an oversight nurse. Communicate resulting treatment recommendations to the patient's PCP (including review of e-consult recommendations if applicable).

• Engage relevant care management staff with patient updates and ensure the care plan is consistently updated and integrated with disease management information.

• Proactively outreach to patients to encourage them become actively engaged in their own health through calm, compassionate communication and by utilizing techniques such as motivational interviewing and behavioral activation.

• Accurately document patient information, assessments, interventions and encounters

• Cross-train in MHN Care Coordinator work functions and execute as required.

• Attend ongoing training and learning related to job position and duties.

• Participate fully in relevant quality assurance and performance improvement measures.

• Provides excellent customer service to internal and external customers

• Assists patients in scheduling and completing referrals as needed by coordinating between the patient, provider(s), and the referral source

• Establish relationships to coordinate patient referrals between patient's provider and referral source to promote patient-centered services and ensure all reports are received by PCC

• Collaborate with providers, and patients to provide patients services needed for successful follow-up

• Advocate on patient's behalf if needed to ensure completion of referrals

• Regularly attend and participate in monthly site/team meetings

• Contribute to patient education materials and strategies to support care coordination

• Work with manager and team to create flow charts, workflows and document tracking process as needed

• Performs other duties as required and assigned

Ability to:

• Work on-site at a PCC clinic at least 3 days per week, which includes community-based visits and travel between PCC sites.
• Follow through, assume responsibility, ensure accountability, and use good judgment
• Strong interpersonal skills, communication skills and confidence and persistence in seeking out providers time to review patient progress.
• Display excellent customer service during in person and telephone contact
• Ability to effectively engage patients in a therapeutic relationship, when appropriate, by telephone or face-to-face.
• Experience with or ability to learn assessment tools and interventions for hypertension, diabetes and mild to moderate depression.
• Work at a computer terminal for extended periods of time on a daily basis

Experience/Training:

• High school diploma or GED required.
• Completed CHW certificate strongly preferred; CHW certification is required to be obtained within 6 months of hire. Up to 40 hours of on-the-job time will be allotted to CHW training, if needed.
• If no CHW certificate, then MA certificate is preferred.
• Knowledge of Chicago's West Side communities (resident of a West Side community preferred)
• English fluency required; Spanish fluency preferred

Preferred experiences include:

• Experience working with underserved, transient populations.
• Experience delivering health education
• Experience working with patients who have diabetes, hypertension and/or depression.
• Basic knowledge of psychopharmacology for common mental health disorders that is within appropriate scope of practice for type of provider filling role.
• Working knowledge of evidence-based psychosocial treatments for common mental health disorders.
• Familiarity with brief, structured intervention techniques (e.g., Motivational Interviewing, Behavioral Activation) and evidence-based counseling techniques (e.g. CBT or PST), when appropriate.

Software Knowledge:

• Experience with MS Office applications Excel and Word required
• Knowledge of EHR (preferably Athena) preferred

Physical Demands:

• Must be able to remain in a stationary position 50% of the time.
• Must be able to move around the clinic site 50% of the time.
• Constantly operates a computer, computer printer, copy machine, and telephone.
• Occasionally positions self to maintain exertion of physical strength to move objects of 10 pounds from one level to another.
• Ability to move as needed to perform necessary assessment face to face and must be able to transport from one site to another.
• Must be able to cover other shifts as necessary.
• This is a hybrid role; onsite requirements will be established by Director and business demands.

PCC funds this position via the Wellness West Collaborative. Should the collaborative end, PCC reserves the right to discontinue the position.