Community Health Coach
The Community Health Worker (CHW) for Smith Island establishes relationships with clients in the community to facilitate appropriate resources, system access to services and communication with the health care team. The CHW-Client partnership is designed to improve self-care abilities and achieve optimal health for the client. CHW services include assisting patients with provider visits through telemedicine; and preventative care with health promotion and education through phone calls, home visits and group classes. The CHW collaborates with a visiting Nurse Practitioner as necessary to partner with clients throughout the health continuum as well as utilizing other community resources to ensure the provision of holistic care. The CHW is responsible for monitoring and evaluating progress toward goals and reporting of outcomes. The CHW adheres to the values of quality, dignity, respect, responsibility/accountability, safety, cooperation, honesty, compassion and integrity. PRMC encourages participation in hospital related or other community activities that improve the well-being of the community. Essential Duties and Responsibilities: Facilitates Provider visits through telemedicine for urgent care as well as follow up visits. Assesses client needs, health patterns, coping skills, and makes recommendations to the NP for care coordination needs. Educates and coaches clients to help them develop self-care and independence appropriate to their age and developmental level. Establishes collaborative partnerships with clients to assist them in examining patterns of health care needs, decisions, lifestyle choices and utilization of resources which affect their health. Acts as a role model to client in development of negotiation skills for interactions with health care system and agency personnel. Collaborates with client, family, health care providers and agencies using multidisciplinary, holistic approach to help the client set goals and achieve desired outcomes. Works collaboratively with inpatient, outpatient, and Telemedicine settings to coordinate seamless care for clients. Utilizes knowledge of CDSM, other resources and NP to obtain resources in the most cost effective manner to best meet clients' developmental, physical, environmental, spiritual, cultural and financial needs. Participates in the development of disease management strategies and the measurement of patient outcomes related to healthcare system utilization and functional status. Participates in program development and improvement. Participates in community presentations/education/groups related to case management/disease management issues. Performs other related duties as assigned. Demonstrates knowledge of the principles of growth and development appropriate to the patient population served. Performs assessment and interprets data on above patient group(s) in order to identify needs, age- appropriate care and interventions, per attached assessment tool. Demonstrates age-appropriate communication and interview techniques. Assesses patients for signs and symptoms of abuse and neglect and refers to appropriate community agency / Nurse Practitioner.
High School graduate or GED required
Chronic Disease Self Management Certification required
Successful Completion of Community Health Worker Training
Candidate must live on Smith Island, Ewell, or Tylerton with ability to reach all clients in the service area in a reasonable timeframe
Effective communication skills.
Computer skills required on an intermediate level with ability to learn the use of telemedicine equipment
Ability to work independently.
Excellent decision-making skills required
Interest and ability to develop interpersonal communication skills and relationships with others.
Expert in basic client assessment and community based resources.
Knowledge of basic personal care, application of adult learning theory, computer applications.
Licenses and Certification
Basic EMT certification or higher is strongly preferred CNA desirable
Current and valid Maryland driver's license and proof of insurance (not necessary for Smith Island).
Current CPR certification.