OUTREACH WORKER

Job Details
Job Location
415 Columbia Rd - Dorchester, MA
Description
Under the supervision of the Senior Manager of Population Health and Support Services the Community Outreach Worker-Neighborhood Trauma Outreach team (NTOT) provides support and linkage to services, advocacy, education, and information in order to ensure optimal health outcomes, increase access of services, and support the patient in self-management of health goals. The Advocate also serves as a cultural bridge to the health care system aiding in identifying and supporting the patient's cultural identity.
DUTIES:

• Assess neighborhoods and individuals following an incident of community violence
• Conduct immediate community outreach (<72 hours after event)
• Ensure individuals and neighborhood impacted by violence receive information on available services
• Complete SDOH for all individual impacted by community violence and address needs.
• Provide direct referrals to primary care and BH services for these community members.
• Increase awareness of Network Partners
• Provides and links patients with community resources and referrals
• Completes needs assessment including Social Determinants of Health as part of outreach
• Provides short term Case Management services for people impacted by violence
• Hel
• Provides a cultural bridge between patients and the health care system
• Works within the Patient Centered Medical Home Model with primary care providers, Behavioral Health, home care providers, and other care team members on complex client situations.
• Assists patients/family with identifying barriers and problem solve solutions and self-management skills.
• Provides direct support on immigration issues including applying for citizenship (N648) and completing the Adjustment of Status
• Participates in various UCHC committees to address the complex needs of patients
• Participates in work groups to pilot strategies to increase arrival rates
• Completes outreach to patients who are newly and chronically lost to follow up
• Works with Care Teams to assist people with new and chronic health illnesses such as Diabetes Mellitus, cardiac conditions, HIV, and others
• Participates with planned outreach/education activities in the community
• Identifies and help resolve potential/actual crises in collaboration with multidisciplinary team.
• Provides cross-cultural interpreter services and education for patients throughout the care continuum
• Conducts home visits after consultation with care teams and management.
• Documents patient/ collateral contacts in the EHR and maintain statistics.
• Participates in quality improvement projects within department and interdepartmentally as needed.
• Attends in-service trainings and outside seminars, as indicated.
• Performs other related duties as required.

Qualifications
• Bilingual in English and Spanish or Cape Verdean Creole, or Vietnamese
• B.A or B.S in related field or three to five years' experience in health and human services
• Excellent inter-personal, computer and writing skills as well as a desire to work in a helping profession with people in need.
• Evening and Weekend flexibility.