The Community Health Specialist (CHS) is an integral member of the Outpatient Care Coordination Department and helps patients access and coordinate their health care. They have the skills to help patients address social problems that lead to poor health. The CHS works to create a trusting relationship with patients and helps them address social determinant of health needs (such as food, housing, transportation) by connecting them to resources. They may schedule follow-up phone calls to ensure progress and will also communicate with the care team as needed. The Community Health Specialist will also support patients in the coordination and completion of appointments inside and outside of the primary care practice. In addition, the CHS will work with patients to help decrease barriers to timely follow-up care. While the CHS is not a clinical position, it requires knowledge of basic clinical concepts and an understanding of when a referral to a licensed clinician is appropriate. They work closely with Social Work team and RN Care Managers in addition to collaborating directly with the Lead Social Worker for clinical guidance and support.

• Follow up with patients post screening surveys to determine a patient's SDoH needs.

• Work with patients to identify and address barriers to care.

• Work with patients and care team members to set goals for patient's care and help to motivate patients to meet their health goals.

• Connect with patients to follow up on key aspects of care and to assess barriers to follow up and compliance.

• Provide culturally sensitive services to patients and working with medical interpreters.

• Provide short term assistance to help patients fill out certain applications for state and federally funded programs such as Disability, Prescription Assistance Programs, and completes PT-1 applications for Mass Health Transportation.

• Document each patient encounter, including SDoH assessments, in detail.

• Assist Care Manager and Social Worker with follow up patient support calls.

• Help to address any logistic barriers, scheduling complications, childcare needs, etc., that would prevent a patient from showing up at their appointment and assists patients with developing plans to get to various medical appointments.

• Refer patients to resources which would include, prescription drug programs, health and wellness programs, long term care insurance, health care proxy, asset and legal management, government programs, community agencies, public & private organizations, housing options and other services, as appropriate.

• Participate in new department staff orientation.

• Advocate for patients to ensure the members safety, physical, legal & financial well-being. Support their caregivers & quality of life goals and help navigate the healthcare delivery system.

• Maintain regular communication with the patient's providers through clinical messages in the electronic health record, emails, phone calls and case review meetings.

• Complete other duties as designated by Practice Manager

Qualifications

EDUCATION REQUIREMENTS:

• High School Diploma required. Bachelor's degree in social work or related field preferred.

• Certified as a Community Health Worker in the Commonwealth of Massachusetts, Equivalent Education and

• Clinical experience or Certification obtained within 1 year of hire.

EXPERIENCE:

• Minimum of 3-5 years' work experience, previous healthcare experience preferred.

EEO Statement

Martha's Vineyard Hospital and Windemere Nursing & Rehabilitation Center are Equal Opportunity Employers. All qualified applicants will receive consideration for employment without regard to race, color, religious creed, national origin, sex, age, gender identity, disability, sexual orientation, military service, genetic information, and/or other status protected under law.