Community Health Worker (Disease Management) - Sinai Chicago

About Us:

At Sinai Chicago, we take health care personally. Excellence in health care is about more than just medicine, technology, tests and treatments, it is about really caring for people with dignity and respect. That’s what we do. We are dedicated to providing the best care to meet the needs of people, for our community, for our patients and for you.

Position Purpose:

The West Side Health Equity Collaborative (WSHEC) 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 WSHEC 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[1]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 WSHEC participating community health centers.

Key Job Activities:

• Completes Health Risk Assessments (HRA) with patients living in target zip codes.
• Assists with community resources and scheduling appointments
• Enrolls eligible patients in disease management program(s) and provide disease specific and preventive care patient education according to program requirements.
• Monitors patients (in person or by telephone) at required frequencies and tracks clinical outcomes such as PHQ-9, blood pressure, HbA1c. Uses a worklist to identify and re-engage patients who are not participating as expected in the disease management program.
• Supports the treatment plan prescribed by PCPs, focusing on treatment adherence, side effects, other complications, and effectiveness of treatment.
• Facilitates 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, subspeciality, mental health specialty care, substance abuse treatment, etc.)
• Prepares for and participates in regularly scheduled caseload oversight with the behavioral health specialist and/or a oversight nurse. Communicates resulting treatment recommendations to the patient’s PCP (including review of e-consult recommendations if applicable).
• Engages relevant care management staff with patient updates and ensures the care plan is consistently updated and integrated with disease management information.
• Proactively reaches out to patients to encourage them to become actively engaged in their own health through calm, compassionate communication and by utilizing techniques such as motivational interviewing and behavioral activation.
• Performs other duties as assigned.

Education and Work Experience:

• High school diploma or GED

Knowledge and Skills:

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

Certifications/Licenses:

• None

Workplace Conditions:

PHYSICAL DEMANDS:

• While performing the duties of this job, the employee is regularly required to sit; use hands to finger, handle or feel; and talk or hear
• The employee frequently is required to walk and stoop, kneel, crouch
• The employee is occasionally required to stand
• The employee must occasionally lift and/or move up to 25 pounds.
• Specific vision abilities required by this job include close vision, distance vision, and ability to adjust focus

WORK ENVIRONMENT:

• General office environment and the noise level in the work environment is usually moderate

BLOOD-BORNE PATHOGEN EXPOSURE CATEGORY:

Category 1 - Job usually involves contact with patients or patient’s specimens. Exposure to blood, body fluids, non-intact skin or tissue specimens, is possible

Category 2 - Job may expose incumbent occasionally or in emergency situations to blood, body fluids, non-intact skin or tissue specimens

x Category 3 - Job does not involve exposure to blood, body fluids, non-intact skin or tissue specimens. Incumbent does not perform or help in emergency medical care or first aid as a part of his/her job.

Benefits:

Sinai Health System’s goal is to provide you with the most comprehensive benefit package possible while balancing our fiscal commitments and obligations. Sinai Health Systems currently offers its employees the option to participate in a full range of benefits, including a health care program which includes medical, dental, vision and prescription coverage. Along with Employer Paid Life and Accidental Death & Dismemberment (AD&D), Supplemental Life, Short-Term and Long-Term Disability, Health Savings Account (HSA) and Flexible Spending Account (FSA), Employee Assistance Program and Student Loan Assistance. Participation in some programs requires that employees be regularly scheduled to work a minimum number of hours and/or to have fulfilled a waiting period after they begin employment with Sinai Health Systems.

Registry (per diem) Caregivers are caregivers who work less than 1,000 hours in a calendar year. Registry caregivers are employees of Sinai Health System but are typically on an as needed basis. These caregivers may be called upon to cover full-time or part-time caregivers during PTO events or sick leave as well as to provide supplemental coverage. Registry Caregivers are not eligible for Sinai’s benefit programs with the exception for Sick-C, PPO Medical Plan, Employee Assistance Program (EAP) and non-match eligible contribution to the Sinai Health System Consolidated 403(b) retirement savings plan.

Living the Values:

• TEAMWORK - Caregiver works together with other caregivers to create and maintain an inclusive workplace where differences, inclusivity, conflict resolution and open communication are valued
• RESPECT - Caregiver shows mutual respect and fairness, treats each person with dignity and encourages each individual’s unique talents and contributions
• QUALITY - Caregiver improves our services by following protocol and suggesting improvements based on observations, continuous learning and industry best practices
• INTEGRITY - Caregiver holds self and others accountable for their actions and are honest and ethical in all dealings
• SAFETY - Caregiver practices behaviors that promote safety for all patients, visitors, and caregivers
• ROLE MODEL - Caregiver is a dependable role model and champions our values through their daily interactions with patients, customers and coworkers

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