Community Health Worker

Community Health Worker Department :

• Allegheny County Department of Human Services Division : Area Agency on Aging Location : 2100 Wharton Street Pittsburgh, PA 15203 Reports To : Community-Based Care Transitions Program Supervisor The Community Health Worker provides thirty-day interventions to targeted patients who are recently been hospitalized.
• The primary role is to identify eligible clients, provide specialized intervention with the goal of preventing avoidable hospitalizations and to empower patients to be the leaders in their healthcare.
• To accomplish this, incumbent will function as an information and referral source, provide a thirty-day intervention to patients and work with hospitals and health plans to prevent readmissions.
• The Health Worker works as a member of the multidisciplinary health care team to ensure that discharge planning critical paths are followed, providing for successful care transitions.
• Essential Duties and Responsibilities Interacts with designated AAA staff, hospital staff and participants when active patients are admitted into the hospital.
• Consults with hospital discharge planners, physicians and multidisciplinary teams to identify patients who would benefit from the Program.
• Conducts assessments of the need for community-based service and support and provides referrals.
• Actively consults and collaborates with hospital multidisciplinary team in planning and executing patient transitions.
• Actively engages patients and caregivers in the discharge planning process using valid and reliable instruments, including a discharge preparation checklist, personal health record, medication reconciliation process and plan for medical follow-up.
• Directs engagement with patients and caregivers to complete the discharge preparation checklist, personal health record, medication reconciliation, as well as identification of educational needs in chronic disease process and self-management skills.
• Visits patient daily at hospital to ensure that patient and family are fully engaged and prepared for care transition process, including necessary tools and competency in self-management skills.
• Provides additional coaching and education as necessary to ensure transition is executed consistently with patient and caregiver goals.
• Visits patients within 48 hours of transition to home or other care setting to review care transition process including adherence with discharge preparation checklist, evaluation of self-management skills, medication reconciliation, caregiver knowledge and self-management skills.
• Recognizes and addresses red flags and plans for medical contact and follow-up.
• Establishes an ongoing plan for home visits and phone contacts specific to patient’s needs.
• Tracks program and individual performance objectives and routinely reports on progress and outcomes.
• Actively participates in readmission reviews with hospital staff and health plans.
• Attends staff meetings and supervision regularly.

Additional Responsibilities From time to time the employee will be required to perform additional tasks and duties as required by the employer.  Knowledge, Skills and Abilities Ability to apply various coaching methodology to cases.