Job type full-time
Full job description
Tampa, florida - tampa, fl
Job title: community health worker (chw)
Reports to: clinical services manager
Department: care delivery
Date: may 2021
About pophealthcare value-based national medical group: our mission is simple leading the effort to reimagine how health care is delivered for our nations most vulnerable seniors and adultsImproving the lives of those most in need guides everything we do, and we believe that as we continue to stay focused on that compass heading we will increasingly be recognized as americas leading national medical group providing in-home and virtual care for those most in need.
Our care delivery model is provenFor more than seven years pophealthcare teams have been delivering the triple aim (enhancing patient experience, better care, lower total cost of care) for those most in need living in ethnically and geographically diverse communities- from urban baltimore, to rural central florida, to upstate new york and across arizonas maricopa county, we are proud of our achievementsWhile delivering exceptional patient experience (2020 enterprise wide nps of 82) we lower the total cost of care (~15-20% across markets), and keep it lower, by delivering more care, not less.
We have brought the same focus to the experience of our own team members as we have to our patients, and through the prioritization of joy in work have made the quadruple aim in health care delivery our clinical true north.
Pophealthcare core care teams are multi-disciplinary and include community health workers (chw), registered nurses (rn), advanced practice providers (app- np/pa), and complex care physicians (ccp), among other care coordination and specialized resources such as palliative care and behavioral health clinicians (physicians and advanced practice providers), as well as social workers (sw), physical therapists, and registered dieticians (rd).
Our care teams understand that vulnerable populations require a new brand of care to live their healthiest life possible- home-based advanced careAdvanced care is comprehensive, and includes medical, behavioral, and social care, and can be delivered either as advanced primary care where our care teams serve as the primary care team or advanced supportive care where our care teams work in partnership with patient pcps to deliver an added layer of support.
Value-based payment methodologies allow our physicians and apps both the time they need to restore the clinician-patient relationship, as well as ensure the patient and clinician are surrounded by a care team that is able to address all of their care needs, especially their behavioral and social needs.
Every day, we care for patients with chronic conditions in their homeWe try our best to keep them feeling well and comfortable so that they can live their lives to the fullestBut life can be tough, which makes it hard for people to stay healthy and get better when they are sickPatients have worries such as: how will i get to the pharmacy to get my prescriptions filled? and will i have food, transportation and enough money? as a community health worker at pophealthcare, the goal is to build a bridge between the patients clinical and social well-being.
We believe that community-health workers (chws) have the skills and experience to understand what our patients and caregivers are going through and help them get through difficult timesChws are people who come from the communities they serveChws act as caring neighbors to help patients address environmental, social, and economic issues that lead to poor healthThe goal is to help patients deal with the real life issues that keep them from staying healthy, help with following a medical care plan, and work on health goals by doing things like planning healthy meals or finding time to exercisePartnering with other care team members increases the likelihood that issues from all aspects of their life impacting their health will be addressed.
The hbapc community health worker is a full-time experienced community health services professional with responsibility for conducting home based and telephonic visits with patients, assessing community and social support needs of patients/caregivers, and to help with patient action plansAs part of a care team, the chw reviews history and documentation prior to completing a visit and recommends additional interventions for the patients action plan and/or facilitates social work and community support for an interim period based upon needHe/she is field-based with some office dutiesThe chw collaborates with the full patient care team (e.gNurse practitioners, nurses, social workers, and physicians) either as a standard member of the care team or based on referral.
Longtime resident of county with great knowledge of resources in the community
Responds to referrals involving:
Unmet social needs impacting care and utilization
Behavioral health issues impacting care and utilization
Issues concerning possible permanent change in level of care, including residential placement
Complex family dynamic issues impacting care and utilization
Social, family, function barriers to care
Assists patients with organizing their records, making follow-up appointments, filling prescriptions, and accessing needed community-based services
Identify and assist with social determinants of health issues like finding transportation, better housing or food resources, financials
Provides culturally appropriate health education and support on lifestyle modifications (healthy diet, importance of exercise, stop smoking)
Completes in-home and telephonic contacts with patients as required
Documents initial/ongoing assessments and action plans in the electronic health record
Follow-up on plans of care and action items
Documents each patient encounter in detail
Works with other chws, local and national to create and maintain a resource book
Assists with the coordination of care and services with community team members
Participates in internal and customer-facing clinical case conferences
Participates in multidisciplinary team meetings
Collaborates closely with the hbapc care team on individualized interventions to improve patient self-management and health outcomes, and any community resources
Communication skills, knowledge of motivational interviewing
Must have a strong desire to build close relationships with all members of the field and regional teams.
Must be committed to working in a collaborative relationship with the members primary care provider.
Excellent time management, organizational skills, and strong communication is a must.
We are searching for a special breed of health care professional who embodies the following qualities and characteristics: heart and commitment to serve vulnerable populations, passion and perseverance to achieve long-term goals (a.k.aGrit), team-based and social determinants of health orientation, and embrace change in a rapidly evolving health care delivery systemFlexible and dynamic, this self-starting individual will be a creative problem solver with a proven track record of successful implementation of innovate health care delivery solutionsThey must possess excellent time management and organizational skills, with the ability to prioritize and multi-taskAdditional qualifications include-
Bi-lingual in english/spanish preferred
Ability to work weekends and evenings if required
High school or ged required,
Associates or bachelors preferred
Preferred 2 years of experience in health or social services
Excellent oral and written communication skills & ability to carry out written and oral instructions
Strong advocacy skills, including the ability to advocate for the patient
Strong interpersonal and relationship building skills
Ability to work independently as well as with a team
Ability to navigate and use an electronic health record for documentation, and working knowledge of computers and ability to document effectively and efficiently in an electronic health record system
Drivers license requirements: licensed for a minimum of 3 years without restrictions; no dui or other felony driving conviction in the past 7 years
Pophealthcare is an equal opportunity/equal access employer fully committed to achieving a diverse w