Community Health Worker- Infectious Disease- Grant Funded

This position will be supporting Hepatitis C patients and connecting them with treatment options. 

Travels within their designated area to enroll, assess and develop care plans for clients who are within medically underserved areas and are in vulnerable populations. Designation as a vulnerable population may be due to: low-income (both insured and uninsured); identified service area; presence of one or more chronic diseases; exhibit risk factors for medical or socioeconomic conditions; be deficient in one or multiple areas of social determinants of health, and under limited circumstances, in areas beyond the defined service area. Identify barriers to health care and services and assist clients to effectively navigate and access needed services and resources.

• Identify potential clients and develop a rapport with clients in order to build trust and productive relationships.
• Conduct a standardized client assessment using a predetermined checklist, preferably during the first visit to the client’s home. Collect demographic data and other client information to effectively address any identified medical, behavioral health, oral health, social, environmental and educational risk factors.
• Document client information in electronic health record or care coordination software systems.
• Have periodic encounters, visits and communication with the clients in order to build and maintain effective pathways for care.
• Collaborate with larger care team to develop, monitor and assess individualized care plans to prioritize and address the clients’ risk factors in order to improve health outcomes.  Each plan consists of a series of pathways designed to address the clients’ identified medical, behavioral health, oral health, social, environmental and educational risk factors.  Assist clients in adopting healthy behaviors and access needed services.
• Ensure the Pathways HUB Model is strictly adhered to in following the appropriate steps, including identifying measurable outcomes.
• Work with supervisors and others who are a part of the care team to identify solutions to close identified gaps, barriers, and deficiencies in access to services and the provision of services.
• Successfully complete orientation and ongoing training, and seek opportunities to expand knowledge and understanding of community needs, resources, services and programs available to meet clients’ needs.
• Work with a variety of agencies and community based organizations, as requested, to identify gaps in services and align initiatives that improve the health of our community.