Maternal and Infant Health Community Health Worker

Job Description

Job Description

Maternal and Infant Health COMMUNITY HEALTH WORKER

JOB DESCRIPTION

DEPARTMENT: Outreach

REPORTS TO: Maternal and Infant Health Navigator/Coordinator or Program Manager

Travel: Local travel may be required for community outreach, community visits, partner meetings, and patient support activities.
Grant Funded: Yes
Grant Period: Position is grant-funded and subject to grant requirements, continued funding, organizational needs, and applicable grant timelines.

POSITION SUMMARY

The Maternal and Infant Health Community Health Worker (CHW) serves as a trusted bridge between pregnant and postpartum patients, infants and families, the healthcare system, and community resources.

Working as an integral member of the maternal and infant health team, the CHW provides culturally responsive, patient-centered, trauma-informed outreach, education, advocacy, and support to individuals and families throughout pregnancy, the postpartum period, and early infancy.

The CHW helps patients and families overcome barriers that may prevent them from receiving timely healthcare and social services. The position builds trusting relationships with patients, assists families in identifying their goals and needs, connects them with appropriate resources, provides approved health education, supports appointment engagement, and follows up to determine whether identified needs have been addressed.

The CHW does not independently provide clinical care or perform duties outside of the individual's training, certification, or scope of practice. The CHW instead works closely with nurses, providers, care coordinators, behavioral health staff, social workers, patient navigators, and other members of the interdisciplinary care team.

The CHW will support the organization's Grow Grant goals and measurable outcomes by helping improve access to prenatal care, postpartum care, infant preventive care, social services, health education, and community-based resources.

ESSENTIAL FUNCTIONS AND RESPONSIBILITIES

1. Patient and Family Engagement

• Establish and maintain trusting relationships with pregnant individuals, postpartum patients, infants, parents, caregivers, and families.
• Serve as a consistent and supportive point of contact for assigned patients.
• Engage patients using respectful, nonjudgmental, culturally responsive, and trauma-informed communication.
• Meet patients where they are and recognize individual strengths, priorities, preferences, and circumstances.
• Encourage patients to participate actively in their healthcare and identify their own goals.
• Provide ongoing encouragement and support throughout the maternal and infant health journey.
• Help patients feel comfortable communicating questions and concerns to their healthcare team.
• Build relationships with patients who may have previously experienced barriers or difficulty engaging with healthcare systems.

2. Social Determinants of Health Support

The CHW will help identify and address social and environmental barriers that may affect maternal and infant health.

Potential needs include:

• Food insecurity.
• Housing instability.
• Transportation.
• Utility assistance.
• Insurance coverage.
• Childcare.
• Employment or financial concerns.
• Clothing and infant supplies.
• Access to technology or communication.
• Language barriers.
• Social isolation.
• Access to behavioral health resources.
• Access to substance-use services.
• Family safety concerns.
• Other basic needs.

The CHW will:

• Assist with approved screenings.
• Discuss identified needs with the patient.
• Provide information about available resources.
• Make appropriate referrals.
• Assist patients with completing applications when permitted.
• Follow up regarding resource connections.
• Document services provided.
• Escalate urgent or high-risk concerns according to organizational policy.

3. Community Resource Navigation

The CHW will maintain knowledge of community programs and resources serving pregnant individuals, infants, children, and families.

Resources may include:

• WIC.
• Public health programs.
• Food assistance programs.
• Housing assistance.
• Utility assistance.
• Transportation programs.
• Childcare resources.
• Early Head Start and Head Start.
• Early intervention programs.
• Home visiting programs.
• Behavioral health organizations.
• Substance-use treatment programs.
• Domestic violence resources.
• Parenting programs.
• Maternal health organizations.
• Infant support programs.
• Faith-based and community organizations.
• Other local social service agencies.

The CHW will provide patients with accurate information and help facilitate connections when appropriate.

4. Referral Support

The CHW will assist patients in successfully accessing referrals and community services.

Responsibilities include:

• Explain the purpose of the referral in understandable language.
• Provide patients with contact information and instructions.
• Assist with scheduling when appropriate.
• Identify barriers to completing referrals.
• Help patients understand what they need to do to access services.
• Follow up after referrals.
• Document referral-related activities.
• Notify the appropriate care team member when a referral has not been completed or additional assistance is needed.

The CHW will not make clinical determinations regarding the appropriateness of a medical referral.

5. Patient Advocacy

The CHW serves as a patient advocate within the boundaries of the position.

Responsibilities include:

• Listening to patient concerns.
• Helping patients communicate questions to the healthcare team.
• Helping patients understand available services.
• Supporting informed participation in care.
• Identifying barriers that may prevent patients from accessing services.
• Helping patients identify potential solutions.
• Supporting patients who may have difficulty navigating healthcare systems.
• Respecting patient choices and self-determination.

The CHW does not make medical decisions or provide medical advice outside of approved training and organizational protocols.

6. Outreach and Community Engagement

The CHW may participate in community-based outreach activities designed to increase awareness of maternal and infant health services.

Activities may include:

• Community health fairs.
• Health education events.
• Outreach events.
• Partner organization events.
• School or early childhood events when appropriate.
• Community presentations.
• Enrollment or resource events.
• Maternal and infant health awareness activities.
• Distribution of approved educational materials.
• Relationship-building with community organizations.

The CHW will represent the organization professionally and consistently with organizational policies.

7. Community

When included within the Grow Grant program model, the CHW may conduct approved community Activities

During these visits, the CHW may:

• Provide approved education.
• Assess non-clinical barriers to care.
• Connect families to community resources.
• Assist with appointment engagement.
• Provide resource information.
• Support care-plan follow-through.
• Follow up on previously identified needs.
• Document the visit and services provided.

8. Care Team Collaboration

The CHW will work closely with the interdisciplinary care team.

This includes collaboration with:

• Maternal and Infant Health Navigator/Coordinator.
• Nurses.
• Providers.
• Medical assistants.
• Behavioral health staff.
• Patient access/registration staff.
• Community partners.
• Other members of the healthcare team.

The CHW will:

• Participate in team meetings and huddles.
• Provide appropriate updates regarding patient barriers.
• Communicate completed interventions.
• Identify patients requiring additional assistance.
• Participate in case review when requested.
• Support warm handoffs.
• Maintain appropriate professional boundaries.
• Escalate concerns promptly.

9. Documentation

The CHW is responsible for accurate and timely documentation of services provided.

Documentation may include:

• Patient outreach attempts.
• Successful patient contacts.
• Community activities.
• Education provided.
• Social needs identified.
• Resources provided.
• Referrals made.
• Referral follow-up.
• Appointment assistance.
• Transportation assistance.
• Care coordination activities.
• Patient goals.
• Barriers to care.
• Outcomes of interventions.
• Grant-required program activities.

Documentation must be completed according to organizational standards and within required timeframes.

10. Electronic Health Record and Technology

The CHW will use the organization's electronic health record and approved technology systems to support patient care and grant activities.

Responsibilities may include:

• Entering patient contacts.
• Recording outreach attempts.
• Documenting interventions.
• Updating appropriate information.
• Reviewing assigned worklists or reports.
• Tracking follow-up activities.
• Using approved communication systems.
• Completing grant-related tracking requirements.

The CHW must protect patient information and follow all HIPAA, privacy, cybersecurity, and organizational requirements.

11. Grow Grant Responsibilities

The CHW will actively support the organization's Grow Grant objectives.

Responsibilities include:

• Understanding the purpose and goals of the Grow Grant.
• Completing grant-funded activities as assigned.
• Meeting established outreach expectations.
• Supporting patient engagement goals.
• Completing required documentation.
• Tracking assigned program activities.
• Supporting collection of grant-required information.
• Participating in program meetings.
• Participating in quality improvement activities.
• Identifying barriers that affect program participation.
• Providing feedback regarding patient and community needs.
• Supporting grant performance measures.

The CHW is responsible for ensuring that work performed under the grant is properly documented and attributable to the approved program.

12. Patient Follow-Up

Consistent follow-up is a core responsibility of the CHW.

The CHW will follow up with patients regarding:

• Missed appointments.
• Referrals.
• Community resources.
• Transportation.
• Social needs.
• Prenatal care.
• Postpartum care.
• Pediatric care.
• Health education.
• Hospital or emergency department follow-up.
• Other identified patient goals.

The CHW will document the outcome of follow-up efforts and escalate unresolved barriers as appropriate.

13. Cultural and Linguistic Responsiveness

The CHW will provide culturally responsive services and recognize the diversity of the patients and communities served.

The CHW will:

• Respect cultural beliefs and practices.
• Use plain language.
• Respect patient preferences.
• Avoid stigmatizing language.
• Practice trauma-informed communication.
• Support patients in identifying their own goals.
• Use qualified interpreter services according to organizational policy.
• Recognize how culture, socioeconomic conditions, transportation, housing, and other factors may influence healthcare access.

Bilingual ability, particularly English/Spanish, is preferred and may be required based upon the population served.

14. Trauma-Informed and Strengths-Based Approach

The CHW will interact with patients using principles of trauma-informed care.

This includes:

• Building trust.
• Promoting safety.
• Providing choices whenever possible.
• Avoiding judgment.
• Recognizing patient strengths.
• Supporting patient autonomy.
• Maintaining appropriate boundaries.
• Avoiding re-traumatization.
• Recognizing when a patient needs additional professional support.

The CHW should focus on what the patient and family can do and what resources can help them succeed, rather than solely focusing on barriers.

15. Safety and Escalation

The CHW must recognize situations that require immediate assistance from clinical or leadership staff.

The CHW will promptly escalate:

• Medical emergencies.
• Behavioral health emergenc