1. Orientation to the role of the Community Health Worker 60-80
2. Understands the following
3. Care New England history/mission & fulfillment of employer’s philosophy; policy and procedures, including “Accountability, Caring, Teamwork” values
4. Co-worker, mentor and supervisory relationships, and support structures such as employee assistance programs, benefits etc..
5. Overview of upcoming regular and specialized social and other employer events
6. Essential philosophy and definition of patient care models including coordinated care
7. Explains in own words “Do no Harm” from the perspective of the CHW
8. Demonstrates familiarity with characteristics of the individual(s) and community(ies) served including socio-economic characteristics, cultures, health & medical concerns

1. Demonstrates adequate familiarity with activities, programs, workflows, culture and staff of CNE operating unit(s) where CHW is based.
2. Uses and understands medical and technical terminology sufficient for efficient and effective communication in the work environment, and appropriate to the CHW role
3. Lists, briefly explains and demonstrates working familiarity with the most common health and medical concerns addressed by their operating unit
4. Integrates efficiently, safely, respectfully and unobtrusively into busy clinical delivery environments
5. Clearly explains CHW role to staff members of all professions
6. Explains the meaning and importance of cultural competence, cultural sensitivity, and cultural humility in own words
7. Carries out culturally appropriate interventions that enhance the functioning of patient/constituent systems
8. Consistently demonstrates reflective practice, particularly regarding his/her own pre-conceptions, in order to support patients/clients from different cultures and communities.

1. Demonstrates general familiarity with mechanisms of data collection and documentation that are used in clinical delivery setting
2. Completes required client documentation, including entering case notes and completing patient action plans
3. Utilizes applicable electronic client record system(s) for managing client health-related and/or social needs information
4. Creates and uses action plans, and closes cases according to protocols
5. Operates and maintains computer and telecommunications equipment in accordance with work requirements
6. May receive training to utilize electronic Health Record System and Health Information Exchange systems, per policy and procedure
7. May receive training to utilize electronic Health Record System and Health Information Exchange systems, per policy and procedure
8. Effectively prioritizes own work in order to complete job responsibilities. Displays ability to adjust priorities based upon understanding of policies and procedures
9. Ensures the timely completion of all required tasks related to screening, referral, navigation, and community access according to program plans, policies, and guidelines
10. Utilizes appropriate technology for reporting and communication
11. Uses reflection to support ongoing organizational learning
12. Complies with all relevant federal, state, local, and internal rules, regulations, reporting requirements and the like
13. Completes job responsibilities within required timeframe, according to established schedules or workflow requirements
14. Displays an ability to evaluate areas in need of improvement and provides input in order to improve current methods, services, programs or technology
15. Reviews and assesses information before making decisions and solving problems
16. Uses proper judgment and knowledge of established practices and procedures when addressing problems or issues

1. Demonstrates understanding of blood borne pathogens and consistently performs universal precautions, infection control and hand washing to standards
2. Demonstrates ability to perform CPR/Basic FirstAid
3. Demonstrates situational awareness, assesses community safety, and engages in practices that ensure employee and client safety, and minimize risk
4. Recognizes and corrects hazards in the workplace and knowledge of protocols for reporting hazards
5. Demonstrates knowledge of strategies to detect and respond appropriately to intimate partner violence (IPV), and applies them as needed
6. Demonstrates the ability to respond appropriately to emergencies
7. Consistently assesses reasonable risk and applies common sense
8. Takes effective safety precautions for home and community visits, and demonstrates ability to politely request modifications or terminate an encounter if safety expectations are not met
9. May provide transportation between clients’ homes and medical or social service settings, and meet with patients in their homes and communities

1. Demonstrates ability to put CHW code of ethics into practice, particularly in difficult or ambiguous situations
2. Functions as a culturally competent practitioner, by understanding the culture of patients, recognizing own biases, and working mindfully and reflectively with this knowledge and insight
3. Protects patients and communities by understanding and consistently applying rules of confidentiality includingHIPAA
4. Explains the Patient Bill of Rights and applies it in practice
5. Works effectively and collaboratively in inter-professional contexts or teams
6. Makes decisions and solves problems consistent with the CHW scope of practice
7. Sets and abides by professional boundaries, and seeks guidance and support in ambiguous or complex situations
8. Demonstrates familiarity with available career and educational paths
9. Consistently applies effective stress management and self-care skills

1. Uses effective and culturally appropriate communication skills including various communication techniques (e.g. teach back) and devices (e.g. apps, smart phones, etc.) and to communicate in person, by phone, and electronically
2. Demonstrates basic group communication and facilitation skills including the ability to make presentations to groups
3. Effectively engages clients and builds healing, trusting relationships
4. Demonstrates effective, efficient and timely documentation
5. Anticipates client needs and proactively suggests strategies to address them
6. Applies knowledge on when to obtain and utilize interpreters

1. Listens to patients actively and without judgement
2. Applies conflict resolution techniques
3. Provides positive support to patients and co-workers
4. Provides effective, positive support for behavior change
5. Utilizes Motivational Interviewing effectively with individual patients, incorporating and applying behavioral change mechanisms and theory

1. Demonstrates mastery of community resource asset mapping – identification and understanding of individual and institutional resources and when to make referrals
2. Uses individualized strategies to help community members navigate social service systems and secure the supports they need
3. Helps patients/community members create and maintain social support systems both formal and informal
4. Explains the importance and relationship of care coordination and transitions of care in own words
5. Applies community organizing and patient advocacy principles
6. Elicits, respects, and actively supports participant choices and preferences
7. Establish, build, and enhance effective communication and working relationships with a wide variety of community service providers
8. Establish, build, and enhance effective communication and working relationships with staff at clinical delivery sites, including nurses, social workers, patient registrars, screening specialists, etc.
9. Shows the ability to assess needs of the community
10. Promotes empowerment and self-confidence and education of individuals/community for self-advocacy
11. Identifies issues related to the population served, particularly upstream factors influencing health and illness
12. Helps individuals and communities to act collaboratively
13. Uses knowledge of common challenges to human, civil and legal rights to benefit the community
14. Understands and may apply principles of health coaching

1. Knows and communicates principles of preventive health and dentistry in using language and concepts patients can understand and respond to
2. Communicates characteristics of a healthy lifestyle in a manner respecting patients’ culture, preferences and strengths
3. Demonstrates basic knowledge of chronic diseases and their relationship to the healthcare system which– according to operating unit – may include diabetes, hypertension, heart disease, stroke, HIV/AIDS, asthma, mental illness, substance abuse, and other health concerns
4. Responds effectively to common health concerns
5. Is able to support individuals in understanding and participating in routine and special health care screening and treatment
6. Communicates principles of safety including - as appropriateenvironmental, personal, and driving
7. Identifies health resources, judges quality, coordinates and communicates with coworkers
8. Recognizes health issues, particularly those relevant to the local community and its social determinants of health
9. May use individualized strategies to help community members manage chronic conditions, including support for medication compliance
10. May perform SBIRT with patients, according to expectations set by program administrators

1. Implements adult learning principles and effective teaching strategies, including ability to customize instructional strategies to meet individual needs
2. Develops mentorship of patients/clients
3. Provides constructive feedback
4. Demonstrates teaching and coaching skills customized to individuals
5. Develops and refines presentation skills
6. Utilizes common A/V equipment and organize materials for presentations

Listed competencies are specific to Screening & Referral Specialists employed by the Community Compass RI program:

1. Implements and complies with Center for Medicare and Medicaid Services and Integra Accountable Health Communities Partnership policies and procedures relevant to screening, referral, and navigation
2. Screens Medicare and Medicaid recipients for health-related social needs (i.e., housing, utilities, transportation, food insecurity, interpersonal violence, family and caregiver support, and physical activity)
3. Performs community service referral and navigation for Medicare and Medicaid recipients who screen positive for health-related social needs (i.e., housing, utilities, transportation, food insecurity, interpersonal violence, family and caregiver support, and physical activity)
4. Establishes rapport and a helping relationship with Medicare and Medicaid recipients with unmet health-related social needs
5. Interviews Medicare and Medicaid recipients with unmet health-related social needs and assist them in choosing appropriate community resources and developing an action plan for addressing unmet healthrelated social needs
6. Assists Medicare and Medicaid recipients in identifying, understanding, and managing barriers to completing their action plans and addressing their health-related social needs
7. Schedules and conducts follow-up visits with Medicare and Medicaid recipients to support progress toward their action plan goals. Visits may take place in clinical, community or home settings as indicated, and over the telephone
8. Identifies cases with critical, immediate need and triage as needed
9. Provides assistance in the supervision and oversight of HRSN screening and referral volunteers
10. Proactively identifies actual and potential screening, referral, and navigation issues and problems and propose solutions to meet those challenges

Introduction to the Community Health Worker Introduction to Public Health/Community Health Concepts and Approaches Introduction to Behavioral Health Health Literacy Practice and Philosophy of Care Ethics and Professionalism Safety and Self-Care Engagement with Clients Promoting Health and Well-Being Care Coordination and System Navigation Advocacy and Leadership Cultural Humility: Appropriate Responsiveness

Poverty in RI Basic Navigator Skills Confidentiality (Not HIPAA) Commonsense Safety Compassion Fatigue Cultural Competency Basics of 2-1-1 Introduction to the Point, Caregivers Alliance Specifics for Community Compass RI access to 2-1-1 service/consultation Basics of Outreach Health of populations: Homeless, Veterans, Addiction, Post-incarceration Medicare 101 Basics of Medicaid Overview of Private Insurance Food Insecurity Housing Insecurity Lead Interpersonal Violence Utility Insecurity Transportation Overview of Integra Overview of Community Compass RI (Accountable Health Communities) Confidentiality and Privacy: Consents, Release of Information, Privacy Notice Review of Best Practices – Client Engagement Screening, Referral and Navigation Workflows Use of Screening Tool, and Screening Manual REACH training-Screening only/Creation of CRS Mental Health 101 Handling IPV REACH Training Navigation REACH practice and simulations Personal Interview Creating and Use of Action Plan Closing Cases

SIBIRT = Introduction to Screening, Brief Intervention, Referral to Treatment in clinical and community settings. This classroom training will be held at Rhode Island College, and taught by their SIBRT Training and Resource Center in Providence, RI.

CHW apprentices will participate in monthly 1-hour interactive presentations with CNE clinical staff as part of the “Health in Context” series. Each session will focus on a common chronic condition or health concern, begin with a brief case presentation, and cover key terms, prevention, treatment, and behavioral, interpersonal & environmental factors that affect the condition. Participants will share their knowledge and insight on how different patients experience the condition, including in different cultural and linguistic contexts. The sessions will conclude with a brief assessment of learning, an open “Ask the Clinician” Q&A designed to address health-related questions that have arisen in professional practice. Topics covered will likely include diabetes, depression & anxiety, substance use, dementia & geriatric care, HIV/AIDS, asthma & COPD, palliative and hospice care, pregnancy, stroke, cancer, etc.

CHW apprentices will engage in monthly 1-hour practice seminars onsite at CNE facilities for 12 months of the apprenticeship facilitated by an experienced CHW, LICSW or similarly trained professional. The intent of the Practice Seminar is to reflect on their professional development, solve problems in a collaborative way, share knowledge and insight from their practice, consolidate lessons learned, and process difficult situations. CHW apprentices will design and complete a capstone project during the course of their final 1-2 months of apprenticeship, designed to integrate and showcase their learning, and reflect on the value of their work to patients and communities. Projects may include a poster session, Powerpoint presentation, narrative project, written product, or similar, and will be presented by CHWs to other staff members Care New England.

CHW apprentices will prepare materials for their certification applications to the RI Certification Board (RICB). Upon conclusion of this activity, they will submit successful applications to RICB and become certified CHWs.

CHW apprentices will participate in a minimum of 7 hours of continuing education opportunities offered at Care New England facilities or through community partners. The goal of the specialty training is to develop skills relevant to a CHW’s particular work setting. Supervisor approval for training is required. Such skills trainings may include: • Behavioral health • Motivational interviewing • Maternal and child health • Housing resources and rights, including HIMIS system • Complex Care management