Lead Care Manager (CHW) (Street Medicine)

Description:

Wellness Equity Alliance (WEA) is a novel national public health organization comprised of a multidisciplinary team of population and public health experts with backgrounds in infectious disease, public health, emergency medicine, primary care, cardiology, pediatrics, psychiatry, community health work (CHW), nursing and advanced practice pharmacy. We work nearly exclusively with underrepresented communities, fundamentally addressing health-care disparities and the social determinants of health (SDoH) that have been amplified during the COVID-19 pandemic, prioritizing the following:

• People experiencing homelessness
• Indigenous communities
• Immigrant communities
• Rural communities
• BIPoC communities
• LGBTQIA+ communities
• Justice-impacted communities

The WEA team is diverse, inclusive, and nimble enough to assemble teams of healthcare professionals within days using our proven local staff recruitment models to address population health crises and communicable disease outbreaks. The WEA team’s partnership model is collaborative and allows hospitals, health jurisdictions, state/local government agencies to provide timely care using equity-based strategies for individuals and marginalized communities.

Purpose of the position

This position is focused on conducting community outreach among unhoused populations. The Community Health Outreach Worker (CHOW) care coordinator will play a crucial role in identifying individuals with active HIV/HCV and STI cases and ensuring they are connected to appropriate care. This includes verifying that patients have received the correct treatment and follow-up care. Staff selected for this role will contribute to a vital and sustainable street medicine program designed to serve unhoused communities in the Victorville area. Often, the most vulnerable individuals experiencing homelessness have encountered repeated failures from institutions throughout their lives, leading to a deep mistrust of authorities, institutions, and healthcare providers. This mistrust, while initially a form of self-protection, can become a significant barrier to accessing care and resources that could significantly improve their quality of life.The street medicine team will work to build trusting relationships with people who are in need of medical services, work to decrease the logistical barriers that block access to health care and provide care directly to the places where unhoused individuals live.

Key Responsibilities

• Assist with daily site/program operations, such as mapping team efforts for the day or week
• Review supplies needed for each patient outreach encounter
• Evaluate program performance through key performance indicators and monitor for improvement opportunities
• Conduct outreach activities within a specific health program and/or defined patient populations with the goal of engaging multiple local businesses, schools, and other relevant organizations in our public and community health services
• Conduct telephonic and/or face-to-face outreach with patients to identify social determinants of health impacting patient's health and overall wellness
• Utilize coaching, motivational interviewing, and other evidence-based techniques to support patients in achieving their goals
• Utilize technology and digital resources to monitor ongoing care activities
• Identify barriers to achieving targeted clinical or social outcomes, and engage the care team to revise the care plan when necessary
• Documents all participant encounters; completes and submits monthly reports; maintains comprehensive electronic participant files. Documents activities, service plans, and outcomes achieved by study participants in an effective manner
• Assists participants in accessing health-related services, including but not limited to: overcoming barriers to obtaining needed medical care and /or social services
• Assists participants in utilizing community services, including scheduling appointments with health resources, and assisting with completion of applications for programs for which they may be eligible
• Works collaboratively and effectively within a team. Establishes positive, supportive relationships with participants and provides feedback to other members of the team. Builds and maintains positive working relationships with the participant, providers, nurse case managers, agency representatives, research staff, supervisors, and office staff, from diverse cultural and socio-economic backgrounds. Works to reduce cultural and socio-economic barriers between participants and institutions
• Provides health coaching, patient navigation, health education and/or health promotion for a diverse patient panel within assigned health program
• Responsible for coordinating with those individuals and/or entities to ensure a seamless experience for the member and non-duplication of services.
• Oversee provision of Enhanced Care Management (ECM) services and implementation of the care plan.
• Offer services where the member lives, seeks care, or finds most easily accessible and within
• Connect member to other social services and supports the member may need, including transportation.
• Advocate on behalf of members with health care professionals.
• Use motivational interviewing, trauma- informed care, and harm-reduction approaches.
• Coordinate with hospital staff on discharge plan.
• Accompany member to office visits, as needed and according to Health Net guidelines.
• Monitor treatment adherence (including medication).
• Provide health promotion and self- management training.
• Manage monthly and quarterly report requests from local, state and Federal entities
• Proficient in Microsoft Office Programs (Word, Excel, PowerPoint), Google Business Suite Programs (Google Docs, Sheets, GCalendar, etc)
• Collaborate with subject matter experts (SMEs) to articulate complex facets of WEA services offerings
• Assist with proposal knowledge management and retention of content for future use
• Manage interns, help supervise and develop associates base on organizational and developmental needs
• Conduct regular meetings with team members to provide guidance and leadership

Requirements:

Essential Skills and Qualifications: As these positions represent some of the early roles to help build this program, we are specifically seeking out individuals with experience developing outreach programs and engaging communities and businesses to engage in meaningful health-care programs

Minimum Qualifications One of the Following

• CHW Certificate
• Violence Prevention Professional Certificate
• Work Experience Pathway

Education Experience

• High School diploma or general equivalency diploma (GED) Associates degree in a healthcare, social work, or related field (Preferred)
• Must possess either a minimum of 5 years of relevant professional experience or lived experience
• Ability to work both independently and to collaborate with teams of individuals in diverse settings, using a solution-oriented approach.
• Preference given to candidates with Community Support Worker (CSW) and/or Certified Peer Support Worker (CPSW) credentials/certifications.