Job Overview:

Functions as an integral part of the Ambulatory Care Management team to support patients with high risk of readmission and/or those with clinically complex chronic conditions. Under the supervision of a nurse or social worker, the Ambulatory Care Management-Community Health Worker provides care coordination and advocacy to patients, including outreach and engagement, linkage of the patient with resources (food, housing, transport, financial, community based services) as well as linking the patient with care. This position provides input into the client’s situation and action plan. Assists patients/families, staff and systems to achieve high quality, evidence-based, cost-effective, and patient-focused outcomes. Providing support services to the PHO and all of its value-based contract members including but not limited to care coordination, home health visits, and counseling.

Job Requirements:

High School Degree
Basic Life Support for Healthcare Providers (BLS)
Knowledge of priority neighborhoods 
Strong oral communication skills and interest in the health of patients and familes

Job Responsibilities:

Collaborates with the care team and serves as a resource to coordinate access to local community agencies and assists families and patients in accessing appropriate services to meet identified needs. Coordinates referrals for services and facilitates contact to community-based organizations on client's behalf, to achieve positive health outcomes. Interacts with clinical and medical personnel across all hospital inpatient and outpatient service lines to ensure collaboration across care settings and meaningful integration at transition points.
Contributes to assessments, gathering information from the patient, family, and caregivers regarding the following: patient's level of functioning, environment, appropriateness and adequacy of support system related to illness and ability to cope. Reports information back to the multidisciplinary care team, and document interventions in patient record. 
Monitors patient's adherence to health improvement or treatment plan. Intervenes with patients and patient's representatives regarding emotional, behavioral, and financial barriers to current illness and/or disability . Conducts patient visits, provider visits and community based visits as needed to ensure effective support and achievement of patient's goals.
Coaches and motivates patients as directed, utilizing behavioral interviewing techniques to identify and address barriers to to effective patient self-management of chronic conditions (i.e. education level, language barriers, etc.) and adherence to treatment recommendations. 
Participates in quality improvement initiatives; activities may include data collection, chart review, interdisciplinary collaboration, analysis of patient data and inter-professional staff meetings.

Other Job-Related Information:

Working Conditions:

Climbing - Occasionally
Concentrating - Frequently
Continuous Learning - Frequently
Hearing: Conversation - Consistently
Hearing: Other Sounds - Frequently
Interpersonal Communication - Consistently
Kneeling - Occasionally
Lifting <10 Lbs - Occasionally
Lifting 50+ Lbs - Occasionally
Lifting 11-50 Lbs - Frequently
Pulling - Occasionally
Pushing - Occasionally
Reaching - Occasionally
Reading - Frequently
Sitting - Frequently
Standing - Frequently
Stooping - Frequently
Talking - Consistently
Thinking/Reasoning - Frequently
Use of Hands - Frequently
Color Vision - Occasionally
Visual Acuity: Far - Frequently
Visual Acuity: Near - Consistently
Walking - Frequently

TriHealth SERVE Standards and ALWAYS Behaviors
At TriHealth, we believe there is no responsibility more important than to SERVE our patients, our communities, and our fellow team members. To achieve our vision and mission, ALL TriHealth team members are expected to demonstrate and live the following: 

Serve: ALWAYS…
• Welcome everyone by making eye contact, greeting with a smile, and saying "hello"
• Acknowledge when patients/guests are lost and escort them to their destination or find someone who can assist
• Refrain from using cell phones for personal reasons in public spaces or patient care areas
Excel: ALWAYS…
• Recognize and take personal responsibility to address and recover from service breakdowns when a customer's expectations have not been met
• Offer patients and guests priority when waiting (lines, elevators)
• Work on improving quality, safety, and service 
Respect: ALWAYS…
• Respect cultural and spiritual differences and honor individual preferences.
• Respect everyone’s opinion and contribution, regardless of title/role.
• Speak positively about my team members and other departments in front of patients and guests.
Value: ALWAYS…
• Value the time of others by striving to be on time, prepared and actively participating.
• Pick up trash, ensuring the physical environment is clean and safe.
• Be a good steward of our resources, using supplies and equipment efficiently and effectively, and will look for ways to avoid waste.
Engage: ALWAYS…
• Acknowledge wins and frequently thank team members and others for contributions.
• Show courtesy and compassion with customers, team members and the community