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Description

Penn Medicine is dedicated to our tripartite mission of providing the highest level of care to patients, conducting innovative research, and educating future leaders in the field of medicine. Working for this leading academic medical center means collaboration with top clinical, technical and business professionals across all disciplines.

Today at Penn Medicine, someone will make a breakthrough. Someone will heal a heart, deliver hopeful news, and give comfort and reassurance. Our employees shape our future each day. Are you living your life's work?

**Job Title:** Community Health Worker

**Department:** Penn Center Community Health Workers

**Entity:** Penn Medicine at Home

**Shift:** Full time, day shift

Community Health Worker (CHW) - Penn Medicine

**Summary:** Are you driven by a passion for helping others and making a tangible difference in your community? Join our team as a Community Health Worker (CHW) and work one-on-one with high-risk patients to set and achieve their health goals. You'll provide social support, navigate the health system, link patients to community resources, and offer behavior change counseling. This autonomous role requires a consistent drive for excellence, effective problem-solving skills, and the ability to make timely decisions with minimal supervision. You'll also collaborate within a multidisciplinary patient care team and ensure thorough and accurate documentation. CHW training will be provided upon hire.

Responsibilities:

Patient Care:

+ **Manage Caseload:** Handle a caseload of 50-100 patients per year, achieving benchmarks such as weekly contact with 100% of patients, resolving at least 60% of patient goals, and receiving a perfect satisfaction rating from at least 90% of patients.

+ **Post-Hospital Follow-Up:** Ensure at least 60% of hospitalized patients attend post-hospital primary care follow-up within two weeks of discharge.

+ **Chronic Disease Management:** Help at least 55% of outpatients achieve the chronic disease management goals they set with their physician.

Patient Interaction:

+ **Needs Assessment:** Meet patients in hospitals or primary care clinics to conduct open-ended needs assessments and understand their health goals.

+ **Motivational Interviewing:** Use motivational interviewing techniques to help patients create action plans for reaching their health goals.

+ **Support and Resources:** Provide a wide variety of support, including emotional support, referrals to community-based resources, social services, and clinical services. Examples include resolving social issues like homelessness, substance abuse, and hunger, assisting with organizing records, making follow-up appointments, ensuring prescriptions are filled, and helping with applications for Medical Assistance and SNAP.

Communication and Coordination:

+ **Weekly Contact:** Make weekly follow-up calls and/or home visits to patients.

+ **Team Collaboration:** Coordinate and communicate with clinical care teams to provide relevant information about patient goals, clinical emergencies, and patient concerns, and to obtain necessary medical information.

+ **Support Group Facilitation:** Co-facilitate a weekly support group for patients.

Community Engagement:

+ **Resource Directory:** Work with other CHWs and staff to create a directory of community resources (e.g., food banks, housing assistance programs, childcare resources) in West and Southwest Philadelphia.

Documentation:

+ **Detailed Records:** Document each patient encounter in detail to ensure accurate and thorough records.

Credentials:

+ **Education and Experience:** High School Diploma/GED required.

+ **Additional Requirements:**

+ Comfortable with home visits and outreach

+ Long-time resident of West or Southwest Philadelphia with good knowledge of community resources

+ Prior experience as an outreach worker

+ IMPACT Community Health Worker Training Certification (provided upon hiring)

We believe that the best care for our patients starts with the best care for our employees. Our employee benefits programs help our employees get healthy and stay healthy. We offer a comprehensive compensation and benefits program that includes one of the finest prepaid tuition assistance programs in the region. Penn Medicine employees are actively engaged and committed to our mission. Together we will continue to make medical advances that help people live longer, healthier lives.

Live Your Life's Work

We are an Equal Opportunity employer. Candidates are considered for employment without regard to race, ethnicity, color, sex, sexual orientation, gender identity, religion, national origin, ancestry, age, disability, marital status, familial status, genetic information, domestic or sexual violence victim status, citizenship status, military status, status as a protected veteran or any other status protected by applicable law.

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