Community Health Worker - Permanent Supportive Housing (PSH)

Overview Reporting to the Manager of Community Health Social Services (MCHSS), the Community Health Worker - Permanent Supportive Housing (PSH) works in collaboration with patients, families (as defined by the patient), and staff across program-specific disciplines and departments to provide care coordination and resource information for patients enrolled in the permanent supportive housing collaborative or receiving services at CommUnityCare, meeting with patients in their homes, community spaces, or in the health center setting. Permanent Supportive Housing (PSH) is permanent housing in which housing assistance (e.g., long-term leasing or rental assistance) and supportive services are provided to assist households with at least one member (adult or child) with a disability in achieving housing stability.

Responsibilities

Essential Duties: Collaborate with all members of the care team in providing patient-centered care. Serve as a point of contact for patients enrolling in PSH Health Care Collaborative. Collaborates with PSH Health Care Collaborative partners, including Integral Care, Central Health, and ECHO on patient-centered care. Provide cultural mediation between community members and CommUnityCare. Interacts with patients via phone calls, medical, or social services appointments, in their home in collaboration with another team member, community spaces on PSH properties, and other locations per program guidelines, to bridge the gap between systems. Empower patients and/or their families to be an engaged and active participant in their care management. Help patients and families set personal goals and attend appointments Coach patients in effective management of their health conditions and self-care. Participates in the identification and intervention of Social Drivers of Health needs for internal and external referrals. Interact respectfully and collaboratively, using a trauma informed care approach, with patients and their families, striving to develop favorable relationships with families. Acts as a patient and family advocate to ensure that services are delivered to meet the needs of patients and families, as well as appropriate use of resources. Coaches and supports patients through the various financial screening applications processes. Completes all direct and indirect care documentation in timely manner and ensure patient records are current and complete. Serve as liaison between the patient and healthcare systems, assisting as needed. Interface with providers and clinic team to ensure that the patient follows with the provider’s treatment plan. Maintains ongoing communication with community partners and attends various community events to promote education and awareness of safety net programs as assigned by Supervisor. Develop and maintain favorable internal relationships, partnerships with co-workers, including clinical managers, clinical support staff, providers and business office staff. Advocate for individual and community health needs and perform outreach activities within the community as assigned by Supervisor. Attends daily patient care (unit) huddles and periodic informational (clinic) huddles, meetings, patient conferences, or planning sessions. These may be related to quality assurance, patient care and other related topics within the clinic and PSH collaborative. Ensure all tasks provided and associated with patient care, patient administrative processes and related duties comply with all regulatory and accreditation standards including The Joint Commission and CommUnityCare Standard Operating Procedures and CommUnityCare Policies and Procedures. Maintain privacy and confidentiality of patient’s medical records and visits. Participates in quality strategies to evaluate compliance with evidence-based guidelines, standards and to identify opportunities to improve patient outcomes. Seeks opportunities and implement goals for own professional development. Attends seminars and maintain all licensure and/or certification requirements for continuing education and best practices. Performs any other duties as needed to drive the vision, fulfill the mission, and abide by the values of this organization.