The CHW Care Team CHW uses their expertise about the community they are working with to provide education about chronic disease prevention and treatment as well as prevention and treatment of acute illnesses including COVID-19. The CHW works within the CHW Care Team to provide a comprehensive approach to address community health needs.

• Engage in community outreach and education about acute and chronic disease screening and health, working in parts of the community where rates of poor health outcomes are high

• Act as a link between patients and health care

• Complete Community Health Worker Certification course within 6 months of being hired

• Complete Blood Pressure Self-Monitoring Program training and/or Diabetes Prevention Program lifestyle coach training as designated by supervisor following hire

• Learn and apply clinic policies and procedures to CHW Care teamwork

• Provide peer support and culturally appropriate education around COVID-19 and other acute illness testing, prevention, and vaccination at community events, office visits and home visits

• Educate community about chronic disease prevention and management, including referral to community lifestyle management programs

• Protect patient information and maintain confidentiality according to HIPAA guidelines

• Engage in relationship-building discussion with patients to find out if there are barriers to health care, and create action plans to access screenings, lifestyle management programs, and appropriate vaccinations

• Support patients as they self-navigate and/or reach out for resources

• Strive to assure each patient can access care across system. Uplift patients to overcome barriers to care with services like peer education, peer support, advocacy, problem-solving, resource connection

• Conduct Self-Monitored Blood Pressure (SMBP) programming, including biweekly Office Hours for walk-in appointments and weekly contact with participants via email, text, or other technology

• Connect community members at-risk for type 2 diabetes to a diabetes prevention program and follow up with participation and goals

• Conduct the National Diabetes Prevention Program as a Lifestyle Coach once the program is established

• Assist participants with high blood pressure and/or type 2 diabetes in logging their self-measured data and reporting that data back to medical professionals

• Log enrollments, educational activities, and referrals

• Participate in weekly CHW Care Team huddles

• Track and follow-up with patients as part of clinical workflows, supporting team-based care

• Collaborate with the CHW Care Team to complete monthly reports in the format provided by KDHE to track progress on goals including enrollments, contacts, success stories, and systems barriers

• When appropriate, participate in community action planning and partnerships to set goals for COVID-19 and chronic disease health equity

• Collaborate with CHW Care team to complete end-of-year success stories and reports
• Will complete other duties as assigned by Program Coordinator.