North Country Hospital

**This is a 2-year grant funded position that is subject to evaluation for renewal**

**This position will be located at the Barton Primary Care Office.**

**Statement of Purpose**

As a member of the North Country Primary Care Community Health Team (CHT), the Community Health Worker (CHW) provides outreach to patients who are currently experiencing challenges in receiving health care and/or other services to support their health. This position provides the opportunity to meet people where they are at and connect them to services, especially those experiencing social and environmental barriers, mental health challenges, and/or struggling with substance use.

The CHW reports to the Community Health Team Supervisor while working closely with the Manager of Population Health and Primary Care leadership in a collaborative manner to best serve the needs of the patient.

**Essential Functions, Duties and Responsibilities**

1. 1. Understands family systems, community resources, health insurance, health care system navigation, and social determinants relevant to improving health outcomes.

1. 1. Works as an embedded member of the Community Health Team within the primary care medical practice to follow up on patient referrals from the clinical team.

1. 1. Supports patients in removing barriers by:
1. Assessing for unmet needs utilizing social determinants of health, mental health, and substance use screening tools.
2. Empowering patients to problem solve and implement strategies to address their needs and goals, focusing on personal and family strengths.
3. Serving as a resource person to patients regarding various community programs by providing information and linkages to those programs.
4. Providing individual support to coordinate services across providers and sites of care to address social, mental health, and substance use needs.
5. Providing general navigation assistance of health and social service systems as well as coordinating referrals to other social services agencies as needed, acting as a patient/family advocate.
6. Arranging transportation.
7. Supporting with the completion of disability applications.
8. Following up with patients who no-show appointments.

1. 1. Works with integrated care team to ensure patient needs are met by:
1. Reviewing completed screening tools to assess and respond to patient needs.
2. Collaborating with internal and external care coordination teams to provide team-based care.
3. Assessing the patient’s needs and readiness for change using motivational interviewing techniques and builds a therapeutic relationship.

1. 1. Participates in required departmental activities:
1. Attends mandatory staff meetings and committee meetings as deemed appropriate by Community Health Team Supervisor and/or Manager of Population Health.
2. Attends and completes all required trainings provided by the VT Blueprint for Health to satisfactorily perform all of the job requirements as deemed appropriate.
3. Completes work assigned accurately and in timely manner.
4. Demonstrates collegiality and commitment relevant to the mission of North Country Hospital and the CHT.
5. Maintains confidentiality of all patients’ records, medical treatments, and diagnoses, and abides by all North Country Hospital policies and procedures.

1. 1. Abides by North Country Hospital’s Compliance Program and Standards of Conduct during term of employment. This is not intended to be construed as an exhaustive list of all functions, responsibilities, skills, and abilities. Additional functions and requirements may be assigned as deemed necessary.

**Working Conditions**

Physical office demands include prolonged sitting/standing and repetitive motions. Patient visits within the community and/or home setting may be required.

**Job Requirements**

1. 1. Education
1. Minimum High School Degree or equivalent.

1. 1. Experience
1. One to three years of experience working in health or social services field. Understanding of those experiencing poor mental health, struggling with substance use or experience with other underserved communities preferred.
2. Experience working in a primary care office or within a Community Health Team preferred but not required.

1. 1. Knowledge and Ability
1. Must maintain a high level of confidentiality.
2. Strong computer and organizational skills are essential, as well as the ability to multitask, respond to shifting priorities, and to work well under pressure while meeting all required deadlines.
3. Ability to work independently while demonstrating the skill to work positively within the framework of a team.