Community Health Worker

Job Title: Community Health Worker (CHW)

Status: Exempt

Reports To: Community Health Manager

Location: Local Market

About Emcara Health Risk-Bearing National Medical Group: Our mission is simple - leading the effort to reimagine how health care is delivered for our nation's most vulnerable seniors and adults. Improving the lives of those most in need guides everything we do, and we believe that as we continue to stay focused on that compass heading, we will increasingly be recognized as America's leading national medical group providing in-home and virtual care for those most in need.

We have brought the same focus to the experience of our own team members as we have to our patients, and through the prioritization of Joy In Work have made the Quadruple Aim in health care delivery our clinical true north.

Emcara Health core care teams are multi-disciplinary and include Community Health Workers (CHW), Registered Nurses (RN), Advanced Practice Providers (APP), and complex care physicians (CCP), among other care coordination and specialized resources such as palliative care and behavioral health clinicians (Physicians and Advanced Practice Providers), as well as Clinical Pharmacists, Pharmacy Technicians, Social Workers (SW), Physical Therapists, and Registered Dieticians (RD).

Our care teams understand that vulnerable populations require a new brand of care to live their healthiest life possible- home-based advanced care. Advanced care is comprehensive, and includes medical, behavioral, and social care, and can be delivered either as advanced primary care where our care teams serve as the primary care team or advanced supportive care where our care teams work in partnership with patient PCPs to deliver an added layer of support.

Value-based payment methodologies allow our physicians and APPs both the time they need to restore the clinician-patient relationship, as well as ensure the patient and clinician are surrounded by a care team that can address all their care needs, especially their behavioral and social needs.

Role Summary: Reporting to the Community Health Manager, the Community Health Worker will serve a critical role within our home-based medical practices. Every day our teams care for patients with chronic conditions. We try our best to keep them feeling well and comfortable so that they can live their lives to the fullest. But life can be tough, which makes it hard for people to stay healthy and get better when they are sick. Patients have worries such as: "How will I get to the pharmacy to get my prescriptions filled?" and "Will I have food, transportation and enough money?" As a Community Health Worker, the goal is to build a bridge between the patient's clinical and social well-being.

We believe that CHWs have the skills and experience to building trusting relationships with our patients, their families, and caregivers, understand what they are going through, as well as help them get through difficult times. CHWs are people who come from the communities they serve. CHWs act as caring neighbors to help patients address environmental, social, and economic issues that lead to poor health. The goal is to help patients deal with the 'real life' issues that prevent them from staying healthy, help with following a medical care plan, and work on health goals by doing things like planning healthy meals or finding time to exercise. Partnering with other care team members increases the likelihood that issues from all aspects of their life impacting their health will be addressed.

An Emcara Community Health Worker is a full-time, experienced, community health services professional responsible for conducting in-person, telehealth, and telephonic visits with patients, assessing community and social support needs of patients/caregivers, and helping with patient action plans. As part of a care team, the CHW reviews history and documentation prior to

completing a visit, recommends additional interventions for the patient's plan of care, and/or facilitates social work and community support for an interim period based upon need. He/she is field based, with some office duties. The CHW collaborates with all members of the homebased medical practice, especially field nurses, Advanced Practice Providers, Behavioral Health Care Managers, and RN Case Managers.

• Strong desire to learn new skills and information to support their patients, including motivational interviewing, behavior change planning, basic knowledge of the chronic
• conditions above, as well as the foundations of the self-management of chronic disease
• Participates in internal and customer-facing clinical case conferences and multidisciplinary team meetings and collaborates closely with the care team on individualized interventions to reduce patients' social needs, as well as improve their self-management and health
• outcomes
• Completes follow-up and documentation tasks as required in the electronic health record
• Works with other CHWs, local and national, to update and maintain a source of community organizations and programs