SUMMARY
The Mobile Clinic is a street medicine multidisciplinary team that will provide medical and behavioral health care to people experiencing homelessness in the unsheltered setting. Direct patient care will be provided in a mobile clinic, encampments and on the streets. The behavioral health unit of the street medicine will include two clinical supervisors, Senior clinical social workers, substance abuse counselors, community health workers, and medical case workers. The patients that will be served include clients with complex medical mental health conditions and those with high risk with complex behavioral health issues. The Mobile clinic CHWs work closely with the medical and social service team within the mobile clinic to provide “wrap around” services to our most vulnerable, complex patients and provide them with health promotion and harm reduction services. The Community Health Worker will be an integral part of the Behavioral Health Team of Mobile clinic providing linkage and resources and case management services to patients in encampments and on the streets. These patients typically have chronic medical conditions, behavioral health issues, and social struggles such as homelessness, substance use disorder, social isolation, illiteracy, and poverty. The CHW provides key interventions that include health coaching, disease self-management support, accompaniment to appointments, and transitions of care support after hospitalizations to prevent readmissions. They also provide linkages to community-based resources and provide support and encouragement to help patients achieve health, improve their health care utilization patterns, and improve their overall wellbeing and function in society. The types of engagement of a CHW may include longitudinal health promotion, short-term stabilization, and ad hoc intervention.
ESSENTIAL FUNCTIONS
- Establishes a trusting, open relationship with complex patients receiving health care within the outpatient setting
- Conducts a baseline needs assessment and works with the patient/family and Clinic team to create a comprehensive care plan
- Arrange for supportive services such as home health care, in home supportive services, or durable medical equipment as needed.
- Link participants experiencing homelessness to the Coordinated Entry System (CES).
- Engage with participants in the most appropriate and accessible location, which may include: the street, shelters, participants’ homes, the hospital, skilled nursing facility or assisted living or other community sites.
- Connect participants to needed resources within the Departments of Health Services, Mental Health and Public Health, and other health and social service providers.
- Using motivation interviewing (MI), CHW motivates and activates the patient to set and achieve personal goals
- Provides health education and counseling around disease management, medication adherence, mental health, addiction, and self-care
- May conduct SBDOH screening and secondary assessments or link patients to SBDOH-related resources as defined by approved workflows and as permitted by successful completion of training and skill validation
- Help participants to build social support systems; this includes connecting participants to support and recovery groups.
- Enhances patient’s health literacy and ability to self-manage / cope with physical disease, substance use disorders, or mental illness
- Assists patient/family with navigating the medical, social service, and behavioral health systems
- Help participants to build social support systems this included connecting participants to support and recovery groups
- Provide coaching for housing, employment, and other interviews and address patients anxieties related to these activities
- Accompanies patients to key medical, behavioral health, and social services appointments and ensure that patients understand and follow through with recommendations made by service providers
- Assists the patient/family around “transitions of care” as patient transfers from one care setting to another and promotes greater use of outpatient resources
- Advocates for patient within clinic and community-based settings to help patient achieve health and life goals
- Completes all required documentation in the electronic medical record related to the services they provide to patients/families.
- Participates in program evaluation and quality improvement projects
- Helps design / implement group sessions for patients on disease self-management or stress management
NON-ESSENTIAL
- Participates in Macro Activities
- Trains/mentors new CHWs and participating in design and delivery of group training sessions
- Represents CHWs on DHS-wide committees assigned to improve care coordination (such as Care Management or Social Determinants of Health work groups)
- Participates in initiatives to focus on “upstream” causes of health disparities within the community or clinic settings such as assisting with a Medical-Legal Partnership program or community-wide fairs to screen community members for hypertension or diabetes.
ADMINISTRATIVE
- Participates in team huddles, case conferences, and multidisciplinary team meetings as needed.
- Participates in performance/quality improvement (PI/QI) activities.
- Shares knowledge and effective practices with other Care Team members.
Education/Experience
Six months of full-time experience working with the public or with community groups performing duties such as interviewing clients or patients concerning health or social service matters, answering questions, and providing information about health, mental health, and social services to clients or patients -OR- Six months of experience at the level of the Los Angeles County class of Mental Health Peer Advocate.
JOB QUALIFICATIONS
- Existing relationships and trust within communities of focus.
- Familiarity working with or navigating within the health and social services system, preferably as a result of lived experience.
- Ability to build and maintain trusting relationships with community stakeholders and health and social service providers.
- Ability to work independently in a constantly changing environment.
- Personal strength, resilience, and stability to allow the CHW, with support of supervisor and work team, to face very challenging situations and avoid re-traumatization and vicarious trauma.
Lived Experience Preferred
- Lived experience in one or more of the communities of focus: people experiencing homelessness, people coming out of incarceration, people with substance use disorder, people continuously admitted to hospitals due to homelessness, women with barriers to a healthy pregnancy, and people with mental illness.
- Member of the community, close affiliation, or shared life experience with the community being served.
- Ability to work appropriately and effectively with patients of the Star Clinic and clients of Housing for Health who reside in Skid Row and across 8 SPAs in Los Angeles County.
- Potential or demonstrated community leadership.
- Experience working with medically and socially complex individuals.
Certificates/Licenses/Clearances
- A valid California driver’s license, proof of vehicle insurance, and reliable transportation or the ability to utilize an alternative method of transportation when needed to carry out job-related essential functions.
- Successful clearance through Los Angeles County’s Live Scan process.
- Successful clearance through the Medical Clearance process.
PHYSICAL DEMANDS
Stand: Frequently
Walk: Frequently
Sit: Frequently
Handling / Fingering: Occasionally
Reach Outward: Occasionally
Reach Above Shoulder: Occasionally
Climb, Crawl, Kneel, Bend: Occasionally
Lift / Carry: Occasionally - Up to 50 lbs
Push/Pull: Occasionally - Up to 50 lbs
See: Constantly
Taste/ Smell: Not Applicable
Not Applicable = Not required for essential functions
Occasionally = (0 - 2 hrs/day)
Frequently = (2 - 5 hrs/day)
Constantly = (5+ hrs/day)
WORK ENVIRONMENT
General Office Setting, Indoors Temperature Controlled
EEOC STATEMENT
It is the policy of Heluna Health to provide equal employment opportunities without regard to race, color, religion, sex, national origin, age, disability, marital status, veteran status, sexual orientation, genetic information or any other protected characteristic under applicable law.
