Community Health Worker, Palliative Care at Home- Full Time

Palliative Care at Home provides home based palliative symptom assessment, treatment and ongoing goals of care discussions for patients and families facing advanced illness.  The full clinical team is comprosed of CHWs, NPs, nurses, social workers and physicians.  The team works in collaboration with patients’ healthcare teams to provide high quality evidence based complex palliative care and chronic care management and is designed to improve symptoms and QOL, reduce caregiver burden, reduce unnecessary inpatient utilization, and facilitate hospice when appropriate. 

DESCRIPTION OF COMPETENCIES

A.   Operational Duties
•    Serve as a link between health and social care services and community to improve access to palliative care 
and quality of care
•    Works as a member of our interdisciplinary care team assessing and addressing the complex care needs 
of patients and families 
•    Develop understanding of the patient and caregivers illness understanding and health literacy  
•    Follow up on goals of care discussions and ensure care plans consider culture and health literacy
•    Monitor patient and caregiver needs
•    Work closely with interdisciplinary team to address changes in patient needs or symptoms
•    Coordinate patient care including but not limited to scheduling appointments, follow up after hospital/ED
•    Educates patient/family on trajectory of illness, use of medications, assesses disease understanding
•    Facilitate virtual visits with providers or nursing visits as needed
•    Promote personal empowerment and engagement in health, including help navigating healthcare system
•    Participate in weekly IDT meeting with care team
•    Monitors care plans in conjunction with the rest of the clinical care team 
•    Documentation as required 
•    Performs other related duties as assigned

B. Knowledge Skills and Abilities
•    Excellent communication skills and ability to connect with patients and caregivers
•    Competence in utilizaing multiple software applications on computer and mobile devices
•    Compassionate with desire to improve care for seriously ill individuals and families
•    Exhibits professionalism patients with staff, patients, caregivers
•    Working knowledge of medical terminology and healthcare system
•    Ability to act as effective advocate for patients and caregivers, ability to work in emotionally charged situations

Required: 
•    High School diploma or equivalent
•    2+ years of experience working with patients in home care environment
•    Experience and comfort working in home settings with patients and families, including difficult living conditions or environments
•    Experience working in interdisciplinary teams 
Preferred: 
•    Certified home health care worker
•    Health coaching certification
•    Palliative/hospice experience
•    Spanish speaking proficiency/fluency