Wellness West Medical Home Community Health Worker

Wellness West is an initiative on Chicago’s west side that uses a comprehensive network of community-based partners and medical providers to screen community members with chronic illness for social determinants of health and provide a suite of comprehensive services to resolve identified issues. Based in the primary care practice, the Wellness West Medical Home Community Health Worker (MH CHW) will work with patients to improve self-management of diabetes, hypertension and mild/moderate depression through assessment, enhanced self-awareness, education, self-monitoring and eliminating barriers to self-care by screening and addressing social drivers of health.

In addition, the MH CHW will serve as a bridge between the patient, the medical system, and community-based organizations by building trusting relationships with community members served by the program. The MH CHW will also help in identifying barriers to accessing quality care, work with individuals to overcome these barriers, provide relevant referrals, follow-up with clients accordingly, and conduct home visits as needed. The MH CHW is employed by Wellness West participating community health centers and reports to the Director of Quality and Risk Management.

Essential Duties and Responsibilities:

• Complete Health Risk Assessments (HRA) with patients living in target zip codes
• Assist with community resources and scheduling appointments
• Enroll eligible patients in disease management program(s) and provide disease specific and preventive care patient education according to program requirements.
• Monitor patients (in person or by telephone) at required frequencies and track clinical outcomes such as PHQ-9, blood pressure, HbA1c. Use a worklist to identify and re-engage patients who are not participating as expected in the disease management program.
• Support the treatment plan prescribed by PCPs, focusing on treatment adherence, side effects, other complications, and effectiveness of treatment.
• Facilitate treatment plan changes for patients who are not improving as expected in consultation with the PCP. These may include changes in medications, treatments, or appropriate referrals for clinically indicated services outside the primary care clinic (e.g., social services such as housing assistance, vocational rehabilitation, subspecialty, mental health specialty care, substance abuse treatment, etc.).
• Prepare for and participate in regularly scheduled caseload oversight with the behavioral health specialist and/or an oversight nurse. Communicate resulting treatment recommendations to the patient’s PCP (including review of e-consult recommendations if applicable).
• Engage relevant care management staff with patient updates and ensure the care plan is consistently updated and integrated with disease management information.
• Proactively outreach to patients to encourage them become actively engaged in their own health through calm, compassionate communication and by utilizing techniques such as motivational interviewing and behavioral activation.
• Accurately document patient information, assessments, interventions and encounters
• Attend ongoing training and learning related to job position and duties.

Education Requirements:

• High school diploma or GED
• Knowledge of Chicago’s West Side communities (resident of a West Side community preferred)
• Demonstrate ability to collaborate and communicate effectively in a team setting.
• Punctual, reliable, and willing to learn
• Ability to maintain effective and professional relationships with patients and other members of the care team.
• Strong interpersonal skills, communication skills and confidence and persistence in seeking out provider’s time to review patient progress.
• Displays high energy, empathy, and organization skills
• Ability to effectively engage patients in a therapeutic relationship, when appropriate, by telephone or face-to-face
• Experience with or ability to learn assessment tools and interventions for hypertension, diabetes and mild to moderate depression.
• Ability and opportunity to work flexible hours.

Desired Requirements:

• Experience working with underserved, transient populations.
• Previous experience in health education
• Experience working with patients who have diabetes, hypertension and/or depression.
• Basic knowledge of psychopharmacology for common mental health disorders that is within appropriate scope of practice for type of provider filling role.
• Working knowledge of evidence-based psychosocial treatments for common mental health disorders.
• Familiarity with brief, structured intervention techniques (e.g., Motivational Interviewing, Behavioral Activation) and evidence-based counseling techniques (e.g. CBT or PST), when appropriate.