Chronic Disease Patient Navigator CHW

Heart of Ohio Family Health is a non-profit organization that operates the following six Federally Qualified Health Centers located in Franklin County, Ohio: Heart of Ohio Family Health at Capital Park, Heart of Ohio Family Health at Canal Winchester, Heart of Ohio Family Health at Mount Carmel East, Heart of Ohio Family Health at St. Ann’s, Heart of Ohio Family Health - James B. Feibel Center, and Heart of Ohio Family Health at Whitehall-Yearling (a school-based site). As a nationally recognized quality leader and patient-centered health care operation, or mission is to provide high-quality, holistic, and compassionate care to meet the healthcare needs of everyone in our diverse community, one heart at a time. We provide healthcare services regardless of ability to pay and offer a sliding fee scale based on income and number of dependents.

Summary: The Chronic Disease Patient Navigator Community Health Worker will work to engage patients with chronic disease such as diabetes and hypertension in care. The position will predominantly communicate with patients via phone and other methods to ensure adherence to their chronic disease care plans. The position will address social determinants of health and education gaps for patients with chronic disease, working closely with medical providers, staff, and other agencies to improve patient care and outcomes.

Reports to: Nutrition Program Manager

Manages: No

Dress Requirement: Business Casual or scrubs

Work Schedule:

Monday through Friday during standard business hours

Times are subject to change due to business necessity

Non-Exempt

Requirements:

• Education or Experience: One-year experience in medical field AND/OR education as community health worker, medical assistant, public health, social services, or similar strongly preferred
• Work experience or life experience working with people with diabetes or hypertension preferred.
• Background check and fingerprinting
• Multilingual candidates (especially those speaking languages most prevalent in Heart of Ohio Family Health’s health centers: Spanish/Somali/Nepali/Haitian Creole) are encouraged to apply. Spanish speaking preferred.

Key Responsibilities:

• Complete outreach calls to patients with chronic disease like diabetes and hypertension who have been lost to care or are due for additional care.
• Complete outreach calls or meet in the clinic with patients with chronic disease to screen for social determinants of health needs and educate on HOFH programs.
• Complete outreach calls to patient enrolled in the Mid-Ohio Farmacy program or to enroll them in the Mid-Ohio Farmacy program.
• Complete outreach calls to patients with chronic disease who have medication to pick up at the pharmacy.
• Act as a preceptor to CHW interns.
• Based on training level of the candidate, educate patients on basics of diabetes and hypertension within scope of practice.
• Assist patients with accessing home blood pressure monitors.
• Help patients develop health management plans and goals.
• Follow-up with health management/care plans with both patients and providers.
• Link patient to resources to help in management of chronic health conditions as needed.
• Assist patient in understanding care plans and instructions.
• Document activities, service plans, and results in an effective manner while strictly adhering to the policies and procedures in place.
• Establish positive, supportive relationships with participants.
• Help clients in utilizing resources, including scheduling appointments, and assisting with completion of applications for programs for which they may be eligible.
• Motivate patients to be active, engaged participants in their health.
• Effectively work with people (staff, clients, doctors, agencies, etc) from diverse backgrounds in reducing cultural and socio-economic barriers between clients and institutions.
• Build and maintain positive working relationships with the clients, providers, nurse case managers, agency representatives, supervisors and office staff.
• Continuously expand knowledge and understanding of community resources, services and programs provided; human relations and the procedures used in dealing with the public as part of a service or program.
• Be a champion in the organization for activities related to diabetes and hypertension.
• Train or educate other staff on programs available for diabetes and hypertension.
• This job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee. Duties, responsibilities and activities may change or new ones may be assigned at any time with or without notice.

Equipment Operated:

Telephone

Computer

Printer

Fax machine

Copier

Scanner

Other office equipment as assigned

Facility Environment:

Heart of Ohio Family Health operates in multiple locations, in Columbus, OH. All facilities have a medical office environment with front-desk reception area, separate patient examination rooms, nursing stations, pharmacy stock room, business offices, hallways and private toilet facilities. All facilities are on the main ground floor and ADA compliant.

The office area is:

• kept at a normal working temperature
• sanitized daily
• maintains standard office environment furniture with adjustable chairs

Physical Demands and Requirements: these may be modified to accurately perform the essential functions of the position:

• Mobility = ability to easily move without assistance
• Bending = occasional bending from the waist and knees
• Reaching = occasional reaching no higher than normal arm stretch
• Lifting/Carry = ability to lift and carry a normal stack of documents or laptop
• Pushing/Pulling = ability to push or pull a normal office environment
• Dexterity = ability to handle and/or grasp, use a keyboard, calculator, and other office equipment accurately and quickly
• Hearing = ability to accurately hear and react to the normal tone of a person’s voice
• Visual = ability to safely and accurately see and react to factors and objects in a normal setting
• Speaking = ability to pronounce words clearly to be understood by another individual