Job Description

Nemours is seeking a Community Health Worker. This Position is part of the CHW Asthma Initiative.

The Community Health Worker (CHW) is a grant funded 3 year position. They will promote the health and well-being of patients and families by providing the re-education of and coaching to families on disease/health management with a focus on asthma and asthma management. The CHW will conduct home visits and healthy home assessments while working with families to promote health and asthma trigger-free households. The CHW will provide case management of non-medical needs to a caseload of high-needs families through regular and ongoing communication ensuring engagement of and a collaborative approach to working with them through an integrated approach to care management and community outreach.

As a priority, CHW activity acts to promote, maintain, and improve the health of patients and their families, provide social support and informal counseling and advocate for individuals and community health needs. The CHW is responsible for: advocating, facilitating, and organizing access to health and social services with/for an identified community to improve the health and well-being of community members. Community outreach, such as calls to the home, home visits and health screenings will be required. The CHW works in the community as well as visiting families in their homes, through virtual visits or in provider offices.

Essential Functions-

1. Establish trusting relationships with patients and their families while providing general support, encouragement and promoting general health and well-being.
2. Advocating, facilitating, and organizing access to health and social services with/for families to improve health and well-being of the community at large, particularly those families who have children diagnosed with asthma.
3. Provide case management of non-medical needs to a caseload of high-needs families through regular and ongoing communication ensuring engagement of and a collaborative approach to working with them through an integrated approach to care management and community outreach.
4. Utilizing EMR to document patient care and communicate with primary care team as well collect data at set intervals though assessment tools collaborating with the leadership to reflect issues that affect health and gauge patient progress.
5. Conduct intake interviews with patients/families, including enrolling and/or referring patients into appropriate community programs. Provide referrals for services to community agencies as appropriate. Identify, create, and nurture relationships with local agencies, schools, churches and other programs that can provide services to children and their families.
6. Provide health re-education on topics related to medications, therapies, health promotion, and informal counseling. Accomplished through partnership with patients' medical team, social work, and care coordinators for follow up with patients/parents via phone calls, home visits and visits to other settings where the patient can be found.
7. Assist in managing care and care transitions for vulnerable populations by establishing supportive relationships with families via regular and ongoing communication to identify and address issues that may contribute to poor health and readmissions. Help patients connect with transportation resources and give appointment reminders as appropriate.
8. Collaborate with the medical and social work team to address and document non-medical issues that affect the health of patients. This includes all social determinants of health needs including but not limited to food insecurity, financial hardships, transportation, housing, violence prevention, etc..
9. Utilize problem solving skills to assist in unusual or difficult patient/family situations. Assist with access to medical insurance, specialty pharmacies.
10. Refer to CHW Asthma Role and Responsibilities

Qualifications-

High School Diploma

Expectations to include,