JOB SUMMARY
The Community Health Worker (CHW) under the direction of the Social Services, Care Coordination Services Coordinator will provide linkage and follow-up services to HIV care. The CHW will conduct outreach/home visits to link patients to HIV services and co-manage the ALERT system Retention in Care program. Outreach activities performed by the CHW will include patients who are not virally suppressed, lost to care, on the margins, unstable due to psychosocial factors, those who could benefit from education on other co-morbid conditions, and as identified by the medical team. They will complete a barriers assessment and address immediate concerns to successfully link and retain clients in HIV care. They will provide referrals to HIV counseling, PrEP education, and assessments at CCHIP Clinics and throughout the CCH facility and community as necessary. The CHW will provide support, advocacy, and encouragement to patients receiving HIV primary care at CCHIP Sites. Further, the CHW will develop professional and trusting relationships with patients and will assist patients in follow-up and execution of case management and medical treatment plans, address barriers to care, and connect patients to appropriate staff to obtain public benefits and entitlements. They will maintain linkage database information and submit monthly reports of program activities to the Care Coordination Services Coordinator, funders, and other administrative staff. The CHW will participate in all administrative and staff development meetings. Flexibility to work evening and/or weekend hours as needed.
SPECIFIC RESPONSIBILITIES
Principal Duties and Responsibilities:
Responsibility: Completes Outreach activities to successfully link HIV positive individuals to any CCHIP, CCH Facility and/or community providers.
Specific Duties:
- Initiates immediate contact with high-risk patients to establish rapport and assist with linkage to care.
- Completes outreach for individuals on the Margin list and offers HIV Linkage services.
- Co-Manages the Care Coordination ALERT system/Rentention Services which generates a real-time text alert for individuals out of care between 7-48 months at any CCHIP site.
- Completes barriers assessments for clients and provides resources to assure engagement in care, i.e., transportation, food resources, etc.
- Assists with assessments and linkage for HIV Positive individuals at Stroger, Jr., Hospital of Cook County.
- Coordinates with Case Managers/Care Coordination/Clinic Team Leads/Medical Providers to identify those that have fallen out of care.
- Conducts outreach/home visits as needed to link & retain patients to HIV care.
- Schedules appointments and assists with addressing barriers to care.
- Completes reminder calls to patients for all CCH appointments & addresses barriers to care as needed.
- Assists with completing Eligibility Assessments, connecting patients to a benefits counselor, reminds them to bring requested and/or other necessary documentation for medical visits and supportive services.
- Provides back-up with Care Coordination Services Department Navigation Program and general linkage and care coordination services as needed.
Responsibility: Assist clients in accessing health-related services, including but not limited to obtaining a medical home, providing instruction on appropriate use of the medical home, overcoming barriers to obtaining needed medical care and/or social services.
Specific Duties:
- Follows up with patients in subsequent visits to assess needs.
- Assists patients in understanding their case management and treatment plans as necessary.
- Communicates with the multidisciplinary care team about individual client’s needs and concerns.
- Attends pre-clinic meetings and client staffing as needed.
Responsibility: Provides back-up assistance as needed with community testing events coordinated by CCHIP at any CCH facility and community settings. Performs pre and post HIV counseling and testing with adults, adolescents, and children, including special populations. Provides linkage services to CCHIP Sites or any other outside or community provider.
Specific Duties:
- Provides pre-test counseling and prevention education at various locations within CCH/CCHIP sites and community events.
- Performs rapid HIV testing through finger stick and/or mouth swab.
- Assesses participants/patients for PrEP Services using CDC guidelines.
- Collects and enters data on HIV testing, PrEP high-risk assessments, and PrEP enrollments for eligible PrEP patients.
- Completes PrEP referrals and submits to PrEP Navigator for immediate follow-up.
- Provides test results, post-test counseling, and assesses client risk behaviors.
- Refers/links HIV positive patients to desired CCHIP site for HIV medical care and other prevention services as needed and schedules future appointments as necessary.
Responsibility: Manage databases.
Specific Duties:
- Enters data and develops monthly reports as requested by department and funders.
- Manages referral process and maintains a referral database.
- Submits monthly/quarterly reports to Care Coordination Services Department and funders.
Responsibility: Database Entry
Specific Duties:
- Documents all face-to-face, phone calls, and collateral contacts in the EMR (Electronic Medical Record) and databases (CAREW ARE/PROVIDE/ Access/Excel/Outlook Calendar).
- Documents client-related activities, referrals including approvals and denials in EMR and databases.
- Maintains up-to-date Outlook Calendar with appointment information on individuals being serviced.
- Submits Data Entry and paperwork in compliance with the Social Services policies.
- Documents transportation, gift cards, and food vouchers as required for internal and external tracking purposes.
Responsibility: Enhance Professional Development and Maintain an Area of Specialization
Specific Duties:
- Discuss areas of specialization and interest with supervisor, seek and receive ongoing training in specialty area (youth, community outreach, and women specific issues), periodically present cases or topics related to specialty area to case management department and/or social service staff.
- Maintain professional competencies.
- Preparation and availability to present both internal and external about the project. Become knowledgeable and provide feedback on the program’s accomplishments and services.
Responsibility: Participate in all CCHIP Center, Social Services & Funder mandatory training and meetings.
Specific Duties:
- Attendance and certificate of completion will go in employee’s record of all mandatory training. Any training that is missed should have supervisor’s approval (i.e., Infection Control, Safety, Customer Service).
Responsibility: Participate in departments Continuous Quality Improvement Efforts
Specific Duties:
- Develop quality improvement processes as assigned.
Responsibility: Adhere to CORE Center and department Specific Policies & Procedures
Responsibility: Provide Excellent Customer Service and Professionalism when interacting with clients/customers internal and external.
Specific Duties:
- Respond to phone calls, emails, faxes, and pages in accordance with the CORE policies.
Responsibility: Other duties as assigned.
Specific Duties:
- Provides clinic, team, or general coverage when a shortage arises.
- Maintain open communication with supervisors and communicate concerns through the appropriate means.
QUALIFICATIONS – Knowledge/Skills/Experience
Minimal Formal Education Required: Minimum of a high school diploma or equivalent. Experience navigating the healthcare system, completing screenings and barrier assessments & familiarity with community resources.
Licensure, Certification, Registration Preferred: Reliable automobile, a valid IL. Driver’s license, and automobile insurance preferred.
Special Knowledge and Skills Preferred:
- A minimum of 2 years’ experience in the HIV field preferred or other chronic disease model.
- Bilingual preferred (Spanish/English).
- 2-3 years working in a medical setting.
- Experience with databases, Microsoft Office Applications, Electronic Medical Record (EMR), Provide and general documentation experience.
- Education on Anger Management, Trauma-Informed Care, Motivational Interviewing, and other population-specific skills.
- Flexibility to work evening and/or weekend hours as needed.
Age-Specifics (Patient Ages and Special Knowledge and Skills): Depending upon assigned specialty area, understand and be aware of the differences in outreach/assessment approaches appropriate to different age groups to provide effective services to HIV Positive individuals in terms of assessment, developmental understanding, communication, and treatment modalities.
EQUIPMENT
Ability to use state-of-the-art office tools (telephone, voicemail, pagers, and computers used for service area documentation).
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