Essential Duties and Responsibilities include the following. Other duties may be assigned:

• Assists individuals and communities in adopting healthy behaviors.
• Conducts outreach to implement programs in the community that promote, maintain, and improve individual and community health.
• Responsible for building and maintaining an active patient case load necessary to meet productivity requirements.
• Liaisons support rapid linkage to care for individuals identified with HCV and/or HIV in emergency and street outreach settings, and act as a warm handoff.
• Coordinates scheduling patients and transitioning their care from inpatient, ED, and outreach teams to the CHASS street medicine team.
• Educates patients on overdose reversal, offers motivational interviews while serving as an essential connection to care.
• Conducts patient outreach and engagement activities to patients, including face-to-face, mail, electronic, and telephone contact.
• Conducts outreach and engagement activities that support patient continuity of care, including re-engaging patients in care if they miss appointments and/or do not follow up on treatment.
• Assists patients in completing patient consent and other clinic or program-related forms.
• Conducts initial and periodic needs assessments using tools to collect Social Determinants of Health (SDOH) data, including assessing barriers and assets (e.g., transportation, community barriers, social supports); patient preferences; and language, literacy, and cultural preferences.
• Supports the development and execution of patients’ care plans, including assisting patients in understanding care plans and instructions, and tailoring communications to appropriate health literacy levels.
• Conducts home visits and accompanies patients to clinic visits per protocol or as determined in consultation with supervisor.
• Promotes patient treatment adherence through assessing patient readiness to make changes; assisting patients in making changes to daily routines; identifying barriers; and assisting patients with developing strategies to address barriers.
• Provides social support and informal counselling, behavioral change support, and assistance with goal setting and action planning.
• Assists patients with navigating health care and social service systems, including arranging transportation, scheduling, and accompanying patients to appointments as determined in consultation with the supervisor.
• Assists care managers in monitoring and evaluating patients’ needs, including for prevention, wellness, medical, specialist, and behavioral health treatment; care transitions; and social and community service needs.
• Identifies available community-based resources and actively manages appropriate referrals, access, engagement, follow-up, and coordination of services to patient supports and resources, including resources related to housing; prevention of mental illness and substance use disorders; smoking cessation; diabetes; asthma; hypertension; self-help/recovery resources; and other services based on individual needs and preferences.
• Documents all efforts to address SDOH issues in the electronic medical record.
• Provides support and education for chronic disease self-management to patients and their families.
• Coordinates access to the basic determinants of health (e.g., food, clothing, shelter, income, utilities).
• Uses health information technology to link to services and resources and communicate among team members, providers, and patients and their families/caregivers.
• Provides information on patients to the healthcare team as appropriate for a greater understanding of patients.
• Electronically documents activities and patient information, and interventions in the patient’s electronic health record.
• Participates in events and projects with collaborating agencies to exchange information and remain current with developments in the field.
• Promotes and educates patients on patient portal access and other CHASS electronic applications.
• Other duties as assigned.

Performance requirements:

Knowledge & Skills:

• Direct experience with or knowledge surrounding communities.
• Knowledge and effective interpersonal skills to work with targeted patients in providing chronic disease or other health education, identifying support needs, developing service plans, and problem-solving. 
• Respond effectively to most sensitive inquiries or complaints.
• Skill in gathering/reporting information, meticulous attention to detail, and record-keeping.
• Experience or training in Motivational Interviewing, knowledge of pertinent health issues, experience in counseling, or working with a diverse population is a plus.

Abilities:

• Ability to deal with frequent changes, delays, and unexpected events.
• Ability to establish positive, supportive, and trusting relationships with and among patients and colleagues and to work collaboratively and effectively within a team, and with patients, family members, community members, and external agencies.
• Ability to develop, adapt, and execute outreach plans.
• Ability to exercise initiative, problem-solving solving and decision-making.
• Ability to operate standard office equipment, including personal computers.
• Knowledge of and ability to facilitate use of the health care system (e.g., primary care and specialty care linkages; appointment scheduling; laboratory and pharmacy services; medical interpreters; eligibility requirements; renewal/recertification; benefits; managed care).
• Knowledge of available social services and resources.
• Health education skills, knowledge of health promotion/wellness, knowledge of chronic disease prevention and management, and knowledge of health condition-specific treatment or management.
• Ability to collect and document data and information.
• Must be able to quickly develop proficiency in patient-tracking systems and care management software.
• Identify and apply appropriate role definition and skilled boundaries.
• Demonstrate reliability and dependability.
• Maintain a professional appearance that is appropriate for the work environment and essential functions.

Special requirements, qualifications, Licenses, or certifications:

• Having actual life experience in homelessness and/or addiction recovery is preferred.
• Experience working as a Community Health Worker with the target population.
• Fluent in Spanish and English Preferred.
• Position may require independent travel to participant homes, and working evenings and weekends as needed to accommodate patient needs and preferences.
• Must have a valid Michigan driver’s license and access to an insured automobile that lists employees on the insurance policy.
• Work experience in helping unhouse individuals and/or Street Medicine environment preferred.
• Must be able to pass a pre-employment background check. Old negative records will be considered not applicable depending on the nature and the time frame.
• Minimum of a high school diploma or GED and a Certified Community Health Worker.

Typical physical demands: Requires prolonged sitting, some bending, stooping, and stretching.  Requires eye-hand coordination and manual dexterity sufficient to operate a keyboard, photocopier, telephone, calculator, and other office equipment.  Requires a normal range of hearing and eyesight to record, prepare, and communicate appropriate reports.  Requires lifting papers or boxes to 35 pounds, occasionally.  It is necessary to view and type on a computer for long periods of time and to work in an environment that can be stressful.

Typical working conditions/environment: Work is performed in an office environment with frequent travel between project activity sites and homes of patient participants.  Work involves frequent contact with staff, patients, program partners, and the public.  Work may be stressful at times.  Community Health Worker will be required to do visits to patients’ homes and other activity sites that are included in Street Medicine team sites.

Accommodation: CHASShas the right to modify the duties and functions of the job description based on the needs of the organization.

Job description review: This job description will be reviewed and updated, if necessary, during the employee’s review.