Community Health Worker

Overview

HRSN Screening and follow-up Management

• For positive screening results, further assess and formulate a plan of care in order to address patient goals.
• Implement the plan of care, including providing health education, facilitating access to needed services such as assists patients in obtaining or stabilizing housing, finances, food, utilities, educational / vocational opportunities, and community supports.
• Monitor patient progress over time, including making referrals to service providers and coordinating care as needed per plan of care-established goals.
• Communicates patient updates to the ICT team and modifies plan of care as needed
• Completes necessary documentation, i.e. (utility assistance, SNAP, disability, SSI, DTA, housing)

Engagement

Transitions of Care