Community Health Navigator

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Overview
To be part of our organization, every employee should understand and share in the YNHHS Vision, support our Mission, and live our Values. These values - integrity, patient-centered, respect, accountability, and compassion - must guide what we do, as individuals and professionals, every day.

At Bridgeport Hospital, we are committed to providing quality medical care and treatment that is coordinated and centered on the patient's specific needs. We strive to achieve benchmarks as a Patient Centered Medical Home and provide health care in a setting where patients are at the center of their care team. All employees of Bridgeport Hospital are part of the patients care team and contribute to the team approach of promoting access, continuous, comprehensive care and work to provide quality improvement in the care provided to their patients.

Works as a key member of the CT Early Detection Program's healthcare team; provides individual and community capacity by increasing health knowledge, literacy and self sufficiency through a range of activitites including outreach, community education, coaching, social support, risk reduction counseling and advocacy. Will serve as a liaison between health and social services and the community to facilitate members' access to services and improve the quality and cultural competence of services delivered.

EEO/AA/Disability/Veteran
Responsibilities
1. Be equipped with tools for mobile secure internet site access to Med-IT and will be able to conduct, in the field, a full baseline health risk assessment as defined by the federal WISEWOMAN program. A mobile kit will be provided with contract funds and include supplies for conducting blood tests (cholesterol, glucose and A1c), taking body measurements (height, weight, circumference and blood pressure), conducting a full health risk assessment questionnaire, conducting risk reduction counseling recording encounter outcome directly into Med-IT, and providing a list of community resources and lifestyle programs available in the area, and
2. Provide education and outreach activities to individuals in target populations promoting enrollment in ACA market-based insurance plans, and encouraging utilization of early detection and prevention services available in Accountable Care ACT (ACA) market-based insurance plans, and
3. Ensure each applicant has been assessed for and referred to available insurance programs before any program services have been delivered,
4. Assess for gaps in coverage or other financial barriers that would deter individuals from engaging in early detection and prevention services offered under their plan,
5. Ensure full compliance with HIPAA by protecting all personally identifying information associated a program participant. Obtain full names and addressed ONLY when a community member is ready and willing to receive program services. Whenever possible, enter personally identifying information directly into the secure internet sites for EncounterCHARTand Med-IT, CT state CEDP database. Return to the participant of shred any pap-based record of personally identifying information before the encounter ends, and.
6. Complete all required screening and assessment baseline components to ensure a valid and complete baseline assessment can be documented for comparison with a future rescreening encounter. This includes physical measurements, completion of a behavior assessment questionnaire and blood test results all as specified by CEDPP Policies and Procedures,
7. Conclude the screening and assessment baseline by delivering risk reduction counseling as prescribed by CEDPP policies and procedures and support each individual to identify and implement strategies and goals to health risk behaviors,
8. For those individuals wanting to make changes in their health risk behaviors, conduct a readiness to change assessment and engage the participant to utilize clinical-community linkages and lifestyle programs identified as part of ongoing community resource scans,
9. Provide special support options to participants identified with uncontrolled hypertension by engaging them in blood pressure self-management and medication therapy management support options to establish long-term hypertension control, and.
10. Provide Health Coaching and motivational support to participants on a routine basis to ensure active and engaged participation their own health outcomes in the promotion of self-care skills and other follow-up care
11. Follow-up with participants from initial identification through closure via phone calls, home visits and visits to other settings where participants can be found, and.
12. Work closely with medical provider and clinical personnel to ensure that participants have integrated, comprehensive and coordinated care
13. Attend regular staff meetings, trainings and other meetings as specified in this contract to ensure a fluid and effective team-based approach to patient-centered care.
Qualifications
EDUCATION
A high school graduate or GED equivalent, Associates Degree Preferred.
EXPERIENCE
Three or more years experience in a healthcare setting interfacing with patients. Must have excellent computer skills and proficiency in WORD, Excel, along with experience in the use of EMRs.
LICENSURE
None
SPECIAL SKILLS
Spanish speaking and CNA a plus. Enjoys working with the public. A Community Health Worker builds individual and community capacity by increasing health knowledge and literacy as well as self sufficiency of community members through a range of activites including outreach, community education, informal counseling, social support and advocacy. Must have excellent communication and interpersonal skills. He/She is a person who is a trusted member of and/or who has an unusually close understanding of the community served in the delivery of health related services through either working directly with providers or their partner organizations.
PHYSICAL DEMAND
Assigned to community field work (at least 24 hours per week) for provision of services for the CT Early Detection Program. CT driver's license.
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