· The primary function of the Care Delivery CHW role is delivering care to CCA’s most complex patients, providing care management and care coordination support, and collaborating with external providers with the goal of delivering comprehensive care.
· Essential Duties Include – best in class patient care; clear, concise, and effective communication and documentation; and interdisciplinary collaboration with a variety of stakeholders internally and externally.
· Engage in regular assessments pertaining to patients Social Determinants of Health
· Conduct visits/outreaches to patients telephonically, virtually, or in-person at regularly scheduled intervals.
· Conduct urgent follow-ups to address patients’ significant social needs (medical or behavioral health)
· Conducts coaching and education towards the promotion of wellness, and the prevention and reduction of health risks.
· Supports the health education needs of the patient in collaboration with the interprofessional care team and PCP
· Assess health risks, identify gaps pertaining to SDOH issues that create barriers to care and/or contribute to unmet needs
· Conducts closed loop communication with patients’ external providers including the PCP and CCAs interprofessional team to identify areas of opportunity, define resources, and coordinate implementation of care plan.
· Collaborate with patients on SDOH goals in care plan and provide support and education for key care management or coordination decisions
· Support efforts to decrease hospitalization utilization such as admissions, readmissions, and emergency department use
· Supports patient retention and connection to Medicaid and Medicare benefits
· Conducts health education on key quality measures including preventative health maintenance and routine medical screenings
· Assists patients in obtaining or stabilizing housing, finances, food, utilities, educational/vocational opportunities, and community supports
· Engages with community agencies and service providers to build relationships to support patients
· Addresses issues regarding substance misuse/abuse, if indicated, in conjunction with Behavioral Health Clinicians and supports
· Uses recovery strategies such as motivational interviewing, harm reduction, positive behavioral support techniques, limit setting, and strengths-based approaches to support patients in attaining stated goals
· Provides 1:1 health education to patients regarding chronic disease self-management to prevent and manage health conditions and encourage development of healthy behaviors/habits
· Serve as a tech literacy coach and support enabling, coaching, and supporting patients with technology to optimize care delivery and care coordination. At times, the CHW will provide 1:1 support for patients in virtual visits with licensed clinicians.
· Documentation and Accountability:
· Documents all visits with focus on clear, comprehensive, and concise charting. Must be able to document in English.
· Completion of all tasks within appropriate timelines as outlines in Scopes of Practice and CCA Guidelines.
· Comply with organization policies and procedures.
· Communicates clear loop closure to HICM interdisciplinary care team and plans for patient centric follow-ups as indicated.
· Identify and initialize a plan to resolve areas of opportunity to meet Key Performance Indicators (KPIs).
· Maintain patient and employee confidentiality.
· Actively participates in the evaluation of own performance and progress
· Provide input to patients care team on key care management/care coordination decisions.
· Interdisciplinary Team Collaboration:
· Proactively and collaboratively work with patient’s Primary Care Provider (PCP) and other external providers to ensure a cohesive medical treatment plan is delivered.
· Conduct on-going and effective collaboration and communication with external providers, including but not limited to Primary Care staff, specialty services, LTSS coordinators, Aging Service Access Points (ASAPs), visiting nurse services, care attendants, patient designated contacts, and next of kin.
· Conduct on-going and effective collaboration and communication with interdisciplinary team including but not limited to, Health Plan Care Team, Community Advanced Practice Clinicians, Community Health Workers, Community Behavioral Health Clinicians, Medical Directors, Palliative Care Team, Psychiatric services team, Rehab Team, Crisis Response workers, Patient Services representatives, administrative staff, and CCA Leaders.
· Participates in weekly interprofessional care team meetings and ad hoc case conferences as needed
· Provides consultation and support to other patients of CCA Care Team
· Participates in ongoing education and training to improve skills and role-specific certifications or specialization.
· Participates in CCA quality improvement efforts
· Assists CCA management and leadership with the development, refinement and enhancement of clinical programs, initiatives, processes, policies, workflows, and projects
· Participates in committees and workgroups that promote clinical excellence and help to advance CCA’s mission and business objectives
· Provides clinical care to patients via telehealth technologies (i.e., video, chat) for clinically appropriate clinical care and care management services
· Other duties as assigned
· Perform any other job related duties as requested.