Job Description

Department: Supportive Services

FLSA Status: Non-Exempt

Supervisor: No 

Leadership Level: Individual Contributor 

Job Function : Essential On-Site 

Hours: 8:30am - 5:00pm

Overview:

The Community Health Worker is responsible for reengaging clients who are connected with Health Care for the Homeless and helping facilitate on-going access to services at Health Care for the Homeless as well as other agencies. As part of an interdisciplinary team, this role will identify barriers and help clients access a variety of resources including specialty care services and housing. The Community Health Worker will also conduct individual health education and risk reduction interventions. 

Key Role Responsibilities:

• Through service provision and regular supports for engagement, build low-demand relationships with assigned clients that results in improved engagement with services.
• Provides supportive services in-home and in the community. These supports can include reminder calls, warm hand-offs, teaching/coaching on activities of daily living, benefit assistance and escorting.
• Escort clients or coordinates transportation to off-site appointments to help facilitate adherence and connection to comprehensive care.
• Problem-solves with clients as barriers arise to help client be successful with identified goals as well as helping them build skills that will be helpful in other circumstances.
• Serves as the eyes and ears of the care team while their clients are in the community and shares information that may be helpful in care plan development.
• Navigates clients through the housing process which may include Baltimore City Coordinated Access system, relocation services, and other housing resources
• Actively participates on an integrated, multidisciplinary team to develop and implement an integrated treatment plan, within the context of an individual or family’s unique social needs, as well as contribute to interdisciplinary case conferences on an ongoing basis.
• Accurately and timely documents all interventions and encounters according to agency policy.

Formal Education and Training:

• High school diploma, GED or equivalent, required ; Associate or Bachelor’s Degree, preferred.
• A valid driver’s license required clean driving record required with own reliable transportation highly preferred.
• Able to attain Maryland Community Health Worker Certification within six months of hire.

Experience:

• At least 4 years of experience reaching out to vulnerable individuals who are often the most difficult to serve.
• At least 2 years of experience in connecting individuals to essential services including healthcare, mental health, and addiction services.
• At least 1 year in a healthcare setting including working with an electronic medical record (EMR) system, relaying medical terminology and working within an interdisciplinary care team.

Skills:

• Knowledge of Baltimore City community resources for addiction, social services and mental health.
• Demonstrates personal integrity and has well-developed interpersonal skills necessary to engage clients and promote positive relationships with other community agencies and providers.
• Able to be flexible and work as part of an interdisciplinary team.
• Able to take initiative and problem solve.
• Able to work with ill, disabled, emotionally upset, and sometimes hostile clients.
• Able to provide outreach services via walking, car, or mass transit.
• Must be able to prioritize and manage own work.
• Bilingual preferred

Why Join Us?

• Be part of a mission-driven team committed to racial equity, social justice, and community wellness.
• Work in a dynamic, people-first organization that centers compassion, authenticity, and hope.
• Receive training and support to grow in your advocacy and peer work.
• Help shape the future of housing and recovery services in Baltimore.

Locations: Baltimore City – Downtown - 421 Fallsway, Baltimore, MD 21202 Baltimore City – West Baltimore - 2000 W. Baltimore St., Suite 3300 Baltimore, MD 21223 Baltimore County - 9150 Franklin Square Dr., Suite 301 Baltimore, MD 21237 Our Vision Everyone is healthy and has a safe home in a just and respectful community. Our Mission We work to end homelessness through racially equitable health care, housing and advocacy in partnership with those of us who have experienced it. Our mission: "...to prevent and end homelessness for vulnerable individuals and families by providing quality, integrated health care and promoting access to affordable housing and sustainable incomes through direct service, advocacy and community engagement." Over 35+ years, we at Health Care for the Homeless have steadily grown and strengthened our approach to care to meet the needs of the vulnerable people we served. We are driven by a single and unwavering goal: to improve access to care for clients, and to provide them with the highest possible quality of care. Continuing in that spirit, we are now implementing a care model that takes quality and access to a new level. A health home delivers person-centered, whole-person care that is evidence-based, uses data and listens to clients to continuously improve the care we deliver. We have been person-centered and focused on the whole person since the first client walked through our clinic doors in 1985. We’ve also always applied evidenced-based standards to our work and used data to inform our care. What’s changed is how much we’ve grown over the years: We have more disciplines, staff members and sites. Coordinating all of our activity today requires a more powerful and standardized way of delivering care. We are a health home. Five areas of focus As a health home, we apply five (5) clinical areas of focus to the care we deliver. ACCESS FOR THOSE WHO NEED US People should be able to reach us easily when they need help. So we ensure 24/7 access to clinical advice; make our appointment schedules and hours flexible and accommodating; and enable clients to access their health records electronically. We also are increasing our presence throughout the community. We have clinics in dowtown Baltimore, West Baltimore and Baltimore County. And we are continually expanding our street outreach and reaching more people with our mobile clinic. TEAM-BASED CARE Whole-person care requires the expertise of many different providers. Done well, it demands collaboration and constant communication among these providers. We are integrating our care providers into multidisciplinary care teams, each with a “panel” of clients, so they can develop care plans that span the range of treatment and services with clients. CARE MANAGEMENT Not only are we committed to providing clients with the best possible care; we are committed to positioning them to manage their own care. To that end, we make sure we know which client groups have the highest needs; we share clients' care plans with them and across their care teams; we provide clients with the tools to care for themselves and we make sure they are part of all decisions relating to their care; and we help them manage their medications. BETTER MANAGE AND COORDINATE CARE People experiencing homelessness often have complex conditions that require intensive care coordination. Our providers specialize in identifying these particularly vulnerable individuals. They provide them with the multi-disciplinary support that keeps them out of hospital emergency rooms, and they help them develop reasonable, healthy goals for themselves. This coordinated and comprehensive care includes helping individuals put a roof over their heads. IMPROVE THE HEALTH OF THE LARGER POPULATION As a population, people without homes have higher rates of chronic disease, such as diabetes, than their housed counterparts. We are using evidence-based guidelines to standardize and expand our assessments for these conditions. And we are continuously seeking ways to help our clients manage and treat their conditions. ________________________________________ Person-centered, whole-person care We provide person-centered, whole-person care, combining health care services and supportive services with advocacy. We provide whole-person care in a safe, respectful environment with acute sensitivity to clients’ life experiences. All have endured trauma; many engage in behaviors that pose a risk to their health. Through a trauma-informed and harm reduction approach, we meet individuals where they are, engage them in care with dignity and work to engage them fully in their own overall wellness. TRAUMA-INFORMED CARE Trauma is central to the homeless experience. People without homes often experience life trauma before they end up on the street, and living on the street is, in itself, traumatic. Trauma affects everything from our ability to trust others and build relationships to our brain development. For these reasons, we at Health Care for the Homeless are committed to providing trauma-informed care, a best practice that recognizes the impact of violence on an individual’s well-being, and that helps heal the social and psychological wounds violence leaves in its wake. HARM REDUCTION Total adherence or abstinence doesn’t work for all who engage in behaviors harmful to their health, like substance use. Harm reduction leverages the relationship between the care provider and the individual to lower the individual’s health risks. Our providers work with individuals to set goals that both reduce harm and are realistic to achieve. Our model of care is known in the health care industry as a patient-centered medical home. Because we provide comprehensive care that goes beyond medical care, we call ourselves a health home. ________________________________________ Health Care for the Homeless is Participating in the Maryland Primary Care Program (MDPCP) Our practice is participating in the MDPCP, a state-wide initiative to improve primary care. To help us provide you with the best care, Medicare will share some of your personal health information with HCH and the State Designated Health Information Exchange (CRISP), to share with other health professionals providing care to you. This will provide us with a more complete picture of your health and allow us to better coordinate your care. For further information and to opt out of data sharing, read more here. ________________________________________ Health Care for the Homeless is accredited for quality: Health Care for the Homeless is an FTCA-deemed facility and is accredited by the Joint Commission for ambulatory care and behavioral health, and as a patient-centered medical home. We invite you to apply and join a welcoming team.

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