BRIEF SUMMARY OF PURPOSE OF POSITION:
Using a care transition model, work with patients being discharged or referred from hospitals or health plans to reduce the chance of re-admission. Focus is placed on coaching and empowering patients to take an active role in their post-discharge recovery and/or healthcare. Effectively educates and links patient and providers to available community-based resources by coordinating with Area Agency on Aging staff. In addition to traditional Community Health Worker responsibilities, this role will further support patients by providing transportation to and from appointments, assist with appointment preparation, be available during the appointment if necessary and requested, and help participant settle back in at home following their appointment.
RESPONSIBILITES AND DUTIES:
• Actively participates in team meetings by providing input in brainstorms, sharing case studies, reviewing readmission trends, and utilizing data feedback to improve processes and outcomes.
• Develop and maintain open lines of communication with care transition hospital partners.
• Work on-site at hospitals, adhering to care transition policies and procedures which have been established with Region VII AAA and partner healthcare delivery organizations.
• Implement the Community Care Transition Initiative model developed by Region VII AAA in accordance with project targets and projected outcomes.
• Conduct home visits with participants of the program, per requirements of the care transitions model.
• Assist participants of the program with basic needs in preparation for scheduled appointments (i.e. help with dressing, toileting, gathering medications).
• Transport program participants to scheduled appointments, assist with entry and exit of vehicle if necessary.
• Accompany program participants into appointment; assist as necessary due to patient mobility.
• If requested by participants, accompany participant into appointment to assist with note taking for care instructions, follow up appointments, etc.
• Ensure participant has needed supplies after appointment (i.e. pharmacy or grocery stop) before returning them home.
• Coach patients in effective management of their chronic health conditions and self-care.
• Coach patients and caregivers on how to access available community resources and interact with healthcare providers as part of their healthcare team.
• Conduct follow-up telephone calls to participants of the program, per requirements of the care transitions model.
• Document activities, service plans, and results in an effective manner while strictly adhering to the policies and procedures that are in place.
• Ability to drive and travel to residential appointments and activities as necessary.
• Ability to plan accordingly and arrive to appointments on schedule; use navigation applications as necessary to determine best route.
• Ensure vehicle is fueled and ready for use; report vehicle repairs as needed.
QUALIFICATIONS & SKILLS:
• High school diploma or equivalent required with experience working in a community-based setting for at least 1 to 2 years preferred.
• Community Health Worker certification required. If not currently certified, must be willing to successfully obtain certification within three (3) months of hire.
• Certified Nursing Assistant certification strongly preferred.
• Valid driver's license with chauffeurs endorsement or willing to successfully obtain within three (3) months of hire.
• Desirable experience includes: customer service, patient/peer coaching, medical patient interaction, community relations, outreach, data entry, public speaking, and non-profits.
• Ability and willingness to provide emotional support, encouragement and motivation to patients.
• Knowledge of some medical terminology preferred.
• Ability to initiate and maintain positive working relationships with staff, clients, and other organizations.
• Understand the community served - community connectedness.
• Have good communication, interpersonal and group processing skills.
• Must be accurate, conscientious and flexible with attention to detail and is proficient with computers.
• Accepts direction, is well organized, and has the ability to meet deadlines.
• This position is subject to the rules/regulations of the hospital and standards which at a minimum include: annual tuberculosis test, flu vaccinations, and vaccinations (or proof of immunity) for MMR, Varicella, Hepatitis B, and potentially others as required.
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