JOB SUMMARY: The Bilingual Community Health Worker III (CHW) under the direction of the Clinical Transition Liaison and the Manager of Patient Centered Care will provide outreach to patients who have fallen out of care at risk to being lost to care or who are not virally suppressed to link them to HIV Primary Care. The CHW III will conduct outreach/home visits as needed to link patients to HIV/HCV services. The CHW will conduct outreach on campus, when alerted through an automated prompt, to relink patients to HIV/HCV services. CHW III will assist patients in follow up, and execution of case management and medical treatment plans. The CHW III will complete the barrier assessment on all patients, and connect patients to the appropriate staff to obtain public benefits and entitlements. The CHW III will obtain a list of Emergency Department patients and ACHN sites, as identified, with positive EIA HIV results and negative confirmatory test results and reviews list for possible follow–up testing, to ensure that acute infections are not missed. Notify providers of discordant HIV results, positive EIA and negative confirmatory, to ensure that Primary Care Provider does not miss acute infections. Maintain database of HIV reactive patients as well as linkage to care services for Emergency Department patients, inpatient, and ACHN sites and submit monthly reports of program activities to the Clinical Transition Liaison, Director of Preventive Health and Education, funder and other administrative staff. Provides pre/posttest counseling and follow up with clients with a reactive result in outreach settings. CHW III will also participate in administrative and staff development meetings.
Perform retention activates to assure successful transition to clinic.
Provide communication to PCMH members and Patient during first and subsequent visits to clinic.
Make appropriate and timely connections to lead case managers to assist patient in understanding their service plan.
Participate in all Multidisciplinary Care Team Meetings.
Adhere to Social Services Documentation Policy of all Patient Encounters and Forms.
Maintain a Working Knowledge of Community and Internal program that would enhance the client’s ability to be maintained in care.
Participate in all CORE Center Meetings and County’s mandatory training and meetings.
Participate in Social Services Continuous Quality Improvement Efforts.
Adhere to CORE Center and Social Services Specific Policies & Procedures.
Provide Excellent Customer Service and Professionals when interacting with clients and internal and external customers.
Provides patient education on HIV, HCV and other common co-morbidities.
Initiates immediate contact with high risk patient to establish rapport and assist with linkage to care.
Conducts outreach/home visits as needed to link patients to HIV/Hepatitis follow up care as needed.
Schedules patient appointments and assists with addressing barriers to care and transportation.
Calls patients to remind them of their appointment.
Assists with connecting patient to a benefits counselor and reminds them to bring necessary documentation.
Provide pre and posttest counseling and prevention education at various locations within CCHHS Bureau entities, including but not limited to Cook County Hospital and the CORE Center.
Refer High Risk negative patients to PrEP clinic.
Database entry and manage databases.
Other duties as assigned.
Special Knowledge and Skills required and preferred
Minimum of a high school diploma or equivalent. The CHW III is someone from the community who is culturally reflective of the clients CORE serves. Bilingual (Spanish/English) preferred. They must have knowledge of HIV treatment and prevention, completion of disease specific training and knowledge. Familiarized with population specific skills, trauma informed care and motivational interviewing. Must engage in self-care activities including but not limited to group/individual support, anger management and street outreach safety. Need to have the ability to document in patient electronic medical records and appointment scheduling. Knowledge and experience working with diverse and complex clients required. Microsoft Office Program, Access, and similar data base experience required. Experience working with clients with multiple needs. Comfortable working with high volumes of clients in a fast-paced environment preferred. Must be flexible with schedule as some evenings and weekends are required.