Job Description

Community Health Outreach Worker

The Community Health Outreach Worker serves as a strategic "frontline bridge," connecting unhoused individuals and those transitioning from the justice system to essential medical, mental health, and housing systems. This role is a vital instrument for ensuring that historically marginalized individuals are not merely maintained in a state of survival, but are actively guided toward economic stability, employment, and self-sufficiency.

The position is dual-natured: it requires the grit and empathy necessary for street-level outreach in encampments and shelters, coupled with the clinical sophistication required for high-level documentation and complex case management. The CHOW will work in an interdisciplinary team and collectively manage a complex caseload. The CHOW should be proficient in navigating digital databases and building trust on the street, building rapport and trust with clients. By focusing on systemic reintegration, the CHOW helps participants navigate the pathway from crisis to financial independence through targeted social service interventions and employment support.

Core Functional Responsibilities

Achieving successful participant outcomes requires a multi-faceted approach where trust built in the field is translated into actionable clinical data and resource linkages.

Outreach and Engagement

• Conduct face-to-face field work: Initiate contact in streets, encampments, and shelters to build trusting, long-term relationships with unhoused individuals.
• Perform street-level screenings: Identify and connect with potential participants, assessing immediate survival needs and establishing a point of entry into the 4th Second service model.
• Logistical Support: Stock and distribute essential information and referral materials to ensure participants have immediate access to resource directories in the field.

Intake and Clinical Assessment

• Complete Assessments: Including the PHQ-2, HMIS Intake, Vulnerability Assessment Tool (VAT), and Risk Assessments to evaluate participant strengths and social risks.
• Navigate complex consent scenarios: Demonstrate expertise in obtaining and reviewing necessary authorizations, including ROIs and agency consent forms, ensuring participants understand their rights and responsibilities.
• Manage administrative clinical tasks: Efficiently handle the faxing and maintenance of internal and external referrals to ensure no delay in service delivery.

Care Coordination and Resource Linkage

• Navigate health and social service systems: Act as an expert guide through complex service webs, ensuring participants attend medical or mental health appointments and navigate complex eligibility criteria.
• Orchestrate post-discharge logistics: Arrange immediate transportation and support for patients being discharged from hospitals to mitigate the risk of re-hospitalization and ensure a seamless transition back to community-based care.
• Facilitate housing stability: Assist participants with the nuances of emergency housing, motel vouchers, and complex applications for permanent supportive housing.

Advocacy and Health Education

• Employ motivational interviewing: Use evidence-based communication strategies to assist participants in goal setting and behavior change, focusing on long-term self-sufficiency.
• Synthesize participant feedback and clinical observations: Act as a professional advocate for the client when collaborating with multidisciplinary teams of nurses and social workers, ensuring the team addresses the client's most acute barriers to care.

Operational excellence in these functions is predicated on the following data standards and meticulous record-keeping.

Data Integrity and Documentation Standards

Data integrity is the backbone of program sustainability and clinical efficacy. Accurate documentation ensures continuity of care and provides the essential metrics required to secure program funding.

Documentation Checklist:

• [ ] Real-time entry into QuickBase and HMIS systems.
• [ ] Expert navigation of patient records and electronic database systems.
• [ ] Maintenance of up-to-date housing status tracking at months 1 through 6 post-placement.
• [ ] Verification of all service data for accuracy, completeness, and HIPAA compliance.

Quality Assurance Expectations:

• 24-Hour Window: All case notes and outreach attempts must be documented within 24 hours of the activity.
• Outreach Frequencies: Document at least one successful (or three unsuccessful) outreach attempts for every client on the caseload each month. Note: Sustaining Tenancy services require two successful attempts.
• Clinical Updates: Annual updates of Blood Pressure (BP) and PHQ records are required for all clients; quarterly updates are mandatory if initial readings were elevated.

High-level technical documentation is essential, but it must be balanced with the human-centric competencies required to operate in the field.

Competencies and Expected Proficiencies

The "Expertise Layer" of this role exists at the intersection of high emotional intelligence and clinical technicality. A CHOW must possess the therapeutic sophistication to independently counsel populations with complex behavioral health needs.

Interpersonal Competencies

Technical Proficiencies

Emotional Intelligence: Managing interactions with deep empathy and perspective-taking.

HIPAA & Data Security: Advanced knowledge of data protection, confidentiality, and EHR platform proficiency.

Trauma-Informed Care: Recognizing and responding to symptoms of trauma in participants.

Harm Reduction: Applying sophisticated strategies to minimize negative consequences of high-risk behaviors.

Conflict Resolution: Utilizing crisis intervention techniques in high-pressure environments.

Resource Expertise: Advanced knowledge of public benefits, financial resources, and family budgeting.

Clinical Depth: Applying advanced therapeutic techniques and clinical judgment in community settings.

Administrative Accuracy: Advanced typing skills and proficiency in Google Docs and Microsoft Office Suite.

Professional Survival Strategies:

• Boundary Setting: The ability to maintain well-defined professional boundaries is essential for the longevity of the employee and the safety of the participant.
• Self-Care Routine: Employees are expected to proactively engage in self-care practices to maintain mental and emotional balance while working in high-stress settings.

Possessing these competencies requires a specific blend of formal education and professional experience.

Qualifications and Requirements

We value a combination of formal academic training and the "lived experience" that grants a practitioner unique credibility when working with unhoused or justice-involved populations.

Minimum Qualifications:

• Education: High School Diploma or GED equivalent.
• Experience: Six months of full-time experience in community outreach, client education, or support services.
• Substitution Rule: Completion of 60 semester units of college coursework (including 6 units of health-related courses) or a formal CHW Certification may be substituted for the 6 months of required experience.
• Technical Skills: Advanced typing skills and proficiency in office software.
• Licensure: Possession of a valid Driver's License and access to reliable personal transportation with a clean DMV record.
• Security: Ability to successfully pass a Live Scan and other required background checks.

Preferred Qualifications:

• Advanced Education: Bachelor's or Master's degree in Social Work, Psychology, or a related field.
• Certification: Formal Community Health Worker (CHW) Certification.
• Language: Bilingual proficiency in English and Spanish.

*Uncertified hires will be expected to obtain CHW certification within one year of hire.

Physical Demands and Environmental Factors

To "meet clients where they are," staff must be prepared to operate in non-traditional settings that do not mirror a standard office environment.

Physical Requirements:

• Mobility: Ability to traverse uneven, sloped, or rocky terrain (e.g., encampments) and walk for durations of 15 minutes or more.
• Exertion: Ability to carry or lift up to 25 lbs and stand or sit for extended periods (1+ hour).
• Operation: Ability to operate a motor vehicle, including during night hours.

Work Environment: The CHOW will be exposed to various environmental factors, including unsanitary conditions and unpredictable daily workflows. Participants may occasionally display challenging behaviors due to untreated medical or behavioral health conditions. 4th Second is committed to staff safety and provides rigorous safety protocols, trauma-informed training, and reasonable accommodations in accordance with applicable laws.

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