The Community Health Worker (CHW) will be an integral member of an interdisciplinary health home care management team. The CHW will work closely with health home patients, care managers, other care management team members, health care providers, social services providers, and community partners to effectively manage the care of designated health home patients.
The Community CAre Transitions (C-CAT) Initiative is seeking an experienced Community Health Worker to join our team. The C-CAT Initiative prioritizes best practice by focusing on patient-centered care, incorporating patient perspectives, and addressing unmet needs and social determinants of health (SDOH) through telephone calls, emails, texts, video visits, home visits (post COVID-19) and collaboration with the patient's care team. By creating space for patients to voice their concerns about their clinical care and what they perceive to be the biggest barriers to staying well outside the hospital, our CHWs bring greater awareness to all members of the interdisciplinary care team, foster patient connections to care teams, and work actively to connect patients to low and no-cost services to close resource and knowledge gaps contributing to sub-optimal care.
The C-CAT Community Health Worker (CHW) will be an integral member of an interdisciplinary home health care management team. The CHW will establish a partnership with patients and work closely with patients' care managers, other care management team members, health care providers, social services providers, and community partners to effectively manage the care of patients during a thirty to forty-five day CHW/patient partnership following hospital discharge.
PRINCIPAL DUTIES AND RESPONSIBILITIES:
- Conduct patient outreach and engagement activities via email, text, electronic and telephone contact including assessment of post discharge needs to patients (Including face-to-face home visits post COVID-19)
- Help patients set personal health goals and support adherence to those goals through identification of barriers
- Conduct outreach and engagement activities that support patient continuity of care following hospital discharge including confirming follow up appointments; ensuring medications access and education; providing PCP and care team contact information
- Conduct initial and interval needs assessments, including assessing social barriers (e.g., transportation, housing/rental, food resources, in home support, insurance, and language, literacy, and cultural preferences, and community-based services)
- Support the execution of patients' care plans, including assisting patients in understanding care plans and instructions and tailoring communications to appropriate health literacy levels.
- Assess patient readiness to make changes utilizing motivational interviewing skills
- Promote patient treatment adherence based on patient's level of readiness to make changes by provide informal counseling, behavioral change support, and assistance with goal setting and action planning.
- Assist patients with navigating health care and social service systems, including arranging for transportation and scheduling and accompanying patients to appointments when appropriate.
- Monitor and evaluate patients' needs, including for prevention, wellness, medical, specialist, and behavioral health treatment; care transitions; and social and community service needs
- Identify available community-based resources and actively manage appropriate access, engagement, follow-up, and coordination of services.
- Coordinate patients' access to individual and family supports and resources, including
resources related to housing; prevention of smoking cessation; diabetes; asthma; hypertension; self-help/recovery resources; and other services based on individual needs and preferences
- Provide support for chronic disease self-management to patients and their families.
- Coordinate referrals for the basic determinants of health (e.g., food, clothing, shelter, income, utilities).
- Use health information technology to link to services and resources and communicate among team members, providers, and patients and their families/caregivers.
- Collect and report on data for program evaluation.
- Provide information on patients to care managers, other care team members, and providers.
- Manually and/or electronically document activities and patient information and interventions in
patient-tracking systems, care management software programs, and other program systems.
- Contribute to a positive experience for patients and families, clinicians and community-based social service organizations through courteous telephone, EMR and email correspondence
- Participate in weekly CCAT team meetings and supportive supervision
- Perform all job functions in compliance with applicable federal, state, local ad company policies and procedures. Knowledge of HIPAA policies, procedures and laws
- Driver's License with verifiable good driving record and reliable transportation
- Completion of a CHW comprehensive outreach education program (e.g. CHEC, BPHC) strongly preferred.
- Creativity, flexibility, sound judgment, and ability to take initiative and work well within a team.
- Excellent time management and organizational skills.
- Demonstrated ability to work both independently and collaboratively.
- Excellent interpersonal skills and demonstrated ability to interact professionally with culturally and educationally diverse staff and clients.
- Positive attitude, ability to show empathy and compassion.
- Proficiency/mastery in written and verbal English language
- Proficiency in completing program assessments and evaluations within a secure/password protected online database (REDCap) preferred.
- Compliance with all MGB Human Resources Policies and Procedures related to job title
- Proficiency in completing program assessments and evaluations within a secure/password protected online database
- Proficiency/mastery of CHW core competencies in providing supportive non-clinical care in patients with co-morbidities including chronic obstructive pulmonary disease, diabetes mellitus, asthma, substance abuse and other chronic disease
- Proficiency/mastery in effectively building health equity through communication, cultural responsiveness, professionalism, patient advocacy, public health application, limit-setting, motivational interviewing, conflict resolution and harm reduction
- Excellent communication skills within an inpatient unit/health care team regarding client concerns
- Verbal proficiency in 1 or more additional languages (other than English) strongly preferred
- Verifiable good driving record and reliable transportation
- Bilingual/bicultural (Spanish) encouraged to apply
- Demonstrated technical experience with Electronic Medical Records in EPIC, Microsoft Word, Excel (or similar databases), and Internet Explorer. Experience with REDCap preferred
- Experience conducting chart reviews, managing lists, and documenting notes in EPIC
- Any combination of 3 years health/social services experience preferably in health care setting or community base organization
- Previous experience working as a community health worker preferred
- While this work is currently 100% remote due to COVID-19 with telephonic, email, text and video visits, the is active movement to return to in-person patient encounters as recommended by MGH/MGB in coming months. The goal of this work is to also partner with case management and nursing teams at the time of patient discharge.
- All work is related to patient support outside the hospital following discharge.
Massachusetts General Hospital is an Equal Opportunity Employer. By embracing diverse skills, perspectives and ideas, we choose to lead. Applications from protected veterans and individuals with disabilities are strongly encouraged