NOAH Community Resource Specialists have a new name – Community Health Workers!
What does this mean?
There are no changes to the scope of work, they will be screening patients for Social Determinants of Health (SDoH) and connecting patients to resources. The only change is that now they are recognized by the state and can be voluntarily certified to provide care.
What does the workflow look like?
Check out the flow chart below. In general, Provider or MA on top of notifying the community health worker via a Teams message, a referral with an appropriate diagnosis needs to be made.
When submitting a referral, I just put “need of community resources” as the diagnosis code or Z code. Why do I need to use one from the list?
Submitting a Z code that is most appropriate and specific, will 1. Help the community health worker determine exactly what service is needed vs. a generic code. 2. Help us expand resources needed in the community.
I don’t have an integrated community health worker in my clinic, what do I do?
Submit an INTERNAL referral to NOAH CRD Copperwood, or NOAH Venado Valley CRD, or NOAH Palomino CRD, etc. (based on the location of the patient). This will help us plan for healthy staffing levels by health center and be sure to add a specific Z code. See frequently used diagnosis from workflow attached.
For health centers that are open Saturdays, what do I do?
Submit an INTERNAL referral to NOAH CRD Copperwood, or NOAH Venado Valley CRD, or NOAH Palomino CRD, etc. (based on the location of the patient). This will help us plan for healthy staffing levels by health center and be sure to add a specific Z code. See frequently used diagnosis from workflow attached.
What are the hours of operation for the community health worker?
Typically, their hours are M-F 8 a.m. to 4:30 p.m., however at times, they may be assisting patients that they needed to follow-up with for additional resources.
What happens when I submit a referral?
The community health worker meets with the patient, if the MA asked the SDoH questions, the community health worker provides resources to patients and documents intervention in electronic health record.
What is an appropriate referral to the community health worker?
The most frequent types of needs they can help are associated with lack of transportation, lack of food, inability to pay for rent/utilities/essentials, and/or unemployment.
I am in Behavioral Health. What diagnosis code do I use?
Please remove any Behavioral Health diagnosis code from the internal referral and use any Z code identified on the workflow.
Who do I contact if I have questions, or I need to escalate a case?
Reach out to Our Community Resource leaders, each leader is assigned to a clinic.
- Cholla and Midtown: Evelin Pulido Obeso
- Venado and Copperwood: Mary Jane Garcia
- Palomino Health Center and Desert Mission Health Center: Griselda Castillo Martinez
You can also email: CRManagement@Noahhelps.org
