| CHW Role | Responsibilities | Examples |
|---|---|---|
| Outreach/In-reach | -Call families -Home visits (cold knock) -Meet families/patients in the hospital or at a specialist appointment. -Send letters or text messages to families | -Home visit for newborn concern -Emergency home visit (same day) if patient has concerning test results and is unreachable (telephone) and unresponsive to hospital correspondence (letters to home, text messages, emails) -In reach if patient is in the hospital -Introduction to CHW during visit or completing a new intake (assessment of family needs)captured at face-to-face visit |
| Navigation and Care Coordination | -Identify barriers to care -Link and inform families about available community resources -Help families enroll into programs -Help families manage and coordinate multiple appointments and provide follow up about attending appointments -Help with care transitions (IP, ED, transition to adult care, specialists for newly diagnosed conditions) – Basic needs: food, clothing, utilities, housing, | -Identifying appropriate resources which best support family’s needs and help reduce barriers to care (transition to shelters, connect with local food pantries, alternative transportation services, reduced or free clothing resources, ) -Enrollment in GED programs, reduced aftercare programs, summer camps, CAP, Financial Assistance Organizations, -Connect with parent support groups -Assist with gaining employment, workforce training and reentry program -Transition to adult care -Help identify barrier when there are multiple no-shows |
| Education/Shared Decision Making* | -Provide and promote culturally appropriate health and wellness education/support for chronic conditions and healthy lifestyle goals -Teach back -Medication management support | -Aid in communicating cultural needs, practices, and beliefs that could affect health or treatment -Help families navigate how to identify specific after hour or weekend resources via apps and the internet -Using teach back methods with visuals for communication with low reading literacy |
| Social-Emotional Support/Advocate | -Attend appointments (medical and other) with families -Articulate and advocate the needs, questions and concerns of families back to the care team | -Attending court sessions (when appropriate) with family for emotional support -Acting as the voice when the family feels they have no voice -Support with language barriers -Aid parent/caregiver who express difficulty understanding instructions from provider -Provide emotional support to a caregiver who feels overwhelmed and has little or no support |
| Motivation/Self-Sufficiency/ Self-Management | -Medication management support -Support families with care plans – Help families with resources to improve their health like nutrition, gym memberships, Healthy Homes referrals, etc. -Goal setting for the entire family -Provide families with the knowledge and teach them the skills to obtain care and other services | -Going over instructions about daily medicine regimens, when to get refills, telephone reminders set to when medicine should be taken -Identify local and community centers which provide 24 or emergency resources services (food pantry, shelter, clothing, etc.) within walking distance of home. – Help families identify free or low-cost programs through their medical insurance plan that support wellness while experiencing a chronic illness -Helping families create realistic goals and how to celebrate the small accomplishments -Working with families on how to change non-productive behaviors which heighten barriers to care |