DescriptionSummary:Working collaboratively as part of a team of Public Health AmeriCorps Community HEART Work (PHACHW) Members, Community Health Workers, clinicians, and administrative professionals, the PHACHW II will utilize advanced community health skills to mentor, provide technical assistance, and review PHACHW I's work and consolidate data and information to be shared with leadership. The PHACHW II will provide screening, referral, and navigation services to connect individuals and their families to social and medical services to resolve their identified needs. The PHACHW II will provide culturally competent patient-centered care to develop a care plan, identifying individual barriers and goals, to improve areas of need. The PHACHW II act