Under supervision, visits individuals and families in their homes, in shelters or other similar places to provide basic community outreach services and to assist with social interventions necessary in coping with a new diagnosis.

May interact with individuals and families at the bedside in the hospital to enroll in community outreach services. Once enrolled, primary communication with patients may be telephonic, face to face or via written material. Community Health Workers will work closely with medical providers, primary care teams and other agencies to improve patient care.

Principal Responsibilities and Tasks

The following statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not to be construed as an exhaustive list of all job duties performed by personnel so classified.

1. Recruits a client base within the community by identifying, locating, interviewing and screening individuals who may be appropriate for Transitional Care Programs including Mobile Integrated Health (MIH) Transitional Care Coordination (TCC) other Care Coordination Programs and High-Risk Clinics such as the Coordinated Care Center (C3).

2. Provides general information to individuals and families on program objectives and services, eligibility requirements and benefits, confidentiality of information, etc. Distributes informational materials and literature.

3. Schedules clients for appointments with health care providers. Reminds them of pending appointments and contacts them to inquire into reasons for missed appointments. Escorts clients to or calls clients to confirm various appointments to ensure compliance and provide support.

4. Assists clients in obtaining necessary transportation and/or childcare when treatment is needed.

5. Assists with client retention by following up on all contacts by telephone or by a home visit follow-up. Locates clients who have moved or lost contact with the program.

6. Serves as a liaison between the client and community resources including department staff, City, State and Federal social services agencies.

7. Conducts visual inspection of the physical condition of the client's house to identify factors that may be detrimental to maintaining a safe, healthy and comfortable living environment.

8. Assists with the facilitation of the health center process by greeting clients and making sure that they are registered to be seen.

9. Assists with planning, organizing and implementing community special events such as health fairs, workshops, etc.

10. Reports on community outreach activities including problems and concerns as needed to the program Administrator.

11. Prepares written reports and maintains records of outreach contacts and activities.

12. Updates information in database from various data forms collected.

13. Achieves monthly, quarterly, annual enrollment goals, determined by yearly program funding.

14. Maintains a good working relationship with all community members to ensure that the various programs they may support are viewed in a positive manner by the community.

15. Continuously expands knowledge and understanding of community resources and services. Facilitates client access to community resources, including locating housing, food, clothing, transportation and providers to teach life skills, and relevant services.

16. Document activities, service plans, and results in an effective manner while strictly adhering to the policies and procedures in place.

17. Implements interventions for the CHW within the care plan established by the care team.