JOB SUMMARY:

As a key member of the NYP Comprehensive Health Program’s patient care team, the Community Health Worker (CHW) helps to improve health care access and outcomes engaging clients into care. The CHW empowers patients to achieve their care goals by providing culturally sensitive education, peer-based support, treatment adherence, and connections to medical care and community-based social supports.

QUALIFICATIONS/CRITERIA:

• 18 years of age, and relevant experience in outreach, social services, and/or sales.
• NYP Clinic operating hours Monday to Friday, 9-5:30pm. Work onsite 2 days in the clinic including the day of assigned team weekly meeting.
• Field work 3 days a week or more, as needed.
• Attend monthly meetings with Agency Supervisor and CHP Sponsor.
• Participate in CHP CHW monthly meetings and other meetings as needed. \
• Work on site at 3 of the Argus Community locations a week including the day of assigned supervision day and attend monthly team staff meetings.

EDUCATION:

• Minimum requirement: HS Diploma or BA degree

• Patient outreach and engagement of out of care, new to care, or at-risk of falling out of care patients seen at the Comprehensive Health Program (CHP), Health Home and non-Health Home enrolled, through phone outreach, home visits, and facility in-reach.
• Accompaniment of Health Home and non-Health Home enrolled patients to HIV medical care, specialty care, social services (e.g., HASA), and community services appointments.
• Work as part of the health care team to deliver quality coordination of care and Health Home care management across settings (hospital-, community-, and home-based).
• Respond to referrals within 24-48 hours, or as determined by referring provider, support patient linkage to agency services, and provide update to care teams to close the loop on referral.
• Conduct home visits to support IT assessments and education for patients living with HIV over 50 years old enrolled in the CHP iPad/hotspot loaner program; supports home-based medication adherence education interventions; and may participate in medication reconciliation with the assistance of an RN care manager through telehealth.
• Participate in clinic-based activities as assigned including attending weekly clinical care team meetings to share updates on patient care plan activities, assisting with Wellness Groups targeting 50+ years old patients, and administering annual screenings on social determinants of health (SDOH) to identify clients in need of housing, food, and transportation support who may benefit from enrollment in the NYP Health Home and/or community services referrals.
• Outreach, engagement, and enrollment of eligible clients into the NYP Health Home program.
• Utilize NYPH EMR to document patient outreach and service provision per CHP and Health Home workflows same day or next day and communicate, as required, with other members of the care team. All health home high-medium-low (HML) assessments must be submitted by the last day of the month.
• Adhere to NYP policy on use of NYP issued IT cell phones, tablets, and other equipment, including the return all NYP property in proper working order at the end of the contract or upon staff termination. Agency may financially responsible for lost or damaged property.
• Additional duties as determined by CHP Sponsor and Program Leadership in consultation with CBO supervisor.
• Report to three of the Argus Community sites and work with assigned HIV/AIDS clients to ensure HIV suppression and their care treatment.