Community Health Worker

ConcertoCare

Description:

The ConcertoCare Community Health Worker (CHW) serves as a key member of a multidisciplinary care team in an integrated care setting, addressing the needs of our most medically and socially complex patients. Our care teams work in concert to bring close attention to patients social determinants of health needs and maintain an intense focus on engaging patients and caregivers in their care. Community Health Workers employ patient activation strategies to support patient engagement, patient education and coaching, and to facilitate access to, and care navigation of, systems targeted at improving health outcomes. This position also engages patients via assisted telehealth.

The CHW role is a critical component of the care teams work to ensure patients meet their care plan goals, and reduce unnecessary utilization of emergency departments and admission/readmission to inpatient units. The Community Health Worker demonstrates deep cultural competency, and leans into patients diverse beliefs, values, and social norms, and ensures care is provided in a manner that is culturally and linguistically appropriate to meet the needs of all patients served. As a key member of the market team, the Community Health Worker also assists with market activities designed to increase patient engagement and participation in ConcertoCares program.

This is an ideal position for a community health-focused professional who seeks an opportunity to integrate the medical, behavioral, and social care needs of highly complex patients, enjoys a collaborative multidisciplinary team-based approach to care, and is excited to engage in developing and nurturing our innovative, value-based clinical model focused on caring for patients with complex medical, behavioral and social needs that the current health system does not serve well.

Responsibilities:

Accept referrals from members of the care team and maintain a panel of patients to support the provision of basic needs impacting patients social determinants of health (housing, food, healthcare access, etc.)

Ensure patients social determinants of health needs are met through effective assessment of needs, identification of appropriate resources, and ensuring patients are accessing available resources both internally and externally

Participate in and support the effective evaluation planning, development, and execution of patient care plan in collaboration with the patients assigned care manager, ConcertoCare provider, and the rest of the patients care team

Follow-up on referrals telephonically and in-person when appropriate, and facilitate effective communication between patients, caregivers, internal and external providers, as well as community-based organizations

Maintain up-to-date community resource inventory to support timely and efficient connection to resources

Employ creative and adaptive strategies to support patients with health literacy needs while simultaneously coaching patients and caregivers to develop advocacy skills when engaging with systems of care

Perform home safety assessments to address barriers to patients remaining independent in their homes and other community residential settings

Demonstrate ability to engage patients in care by persistently forging trusting relationships through effective rapport building and use of evidence-based practices such as Motivational Interviewing

Coach patients on problem-solving, self-care, and self-management to close care gaps and to teach skills for health promotion and prevention

Partner with patients and caregivers to address barriers that get in the way of adopting a healthier lifestyle (i.e., smoking cessation, weight loss)

Use digital tools such as a web-based resource finder to assist patients in improving health outcomes, supporting p