Community Health Worker II

Key Areas of Responsibility:

• Works as an effective team member of the MGHfC and DGIM population health management program to provide health coaching and care coordination to patients and families.

Principle Duties and Responsibilities:

Patient Engagement and Health Coaching

• Meet with patients in person or virtually once/month with the multi-disciplinary team, with a focus on goal setting, physical activity promotion, and connection to community resources to improve patient outcomes.
• Connect families with community organizations/activities that promote a healthy lifestyle.
• Phone call communication with families to support clinic expectations, attendance and goals.
• Facilitation of weekly group visit sessions with families (virtually and in-person), based on a set curriculum. CHAMPION CHW will be responsible for reminder calls, conducting the visit, and all associated planning activities.
• Provide culturally sensitive services to patients from diverse racial, cultural, and socioeconomic backgrounds; utilize medical interpretation as needed.
• Participate in the Virtual Learning Community, and Quality Improvement calls and activities.
• Other duties include keeping strong communication between the different components of the research, clinical, schedules and patient care.

Systems Navigation and Care Coordination

• Help address logistical barriers, scheduling challenges, childcare needs, etc., that would inhibit a patient from showing up at their appointment; help patients to develop plans to get to appointments.
• Assist patients in organizing their records, making follow-up appointments, filling their prescriptions, and understanding past medical history.
• Work with primary care providers to reinforce provider care plans and health education messages, the importance of follow-up care, medication adherence, routines of self-care, etc.
• Provide advocacy, patient education, and support in accessing community-based and hospital-based programs.
• Support timely scheduling, communication, and problem-solving across areas to ensure program excellence.
• Refer to internal or external case management services within the practice when other issues are identified (i.e., food insecurity, domestic violence issues, etc.)

Collaboration and Documentation

• Document each patient encounter in detail. Track benchmarks of progress in care, including short-term goal completion.
• Maintain regular communication with the patient's providers (through clinical messages in EPIC, emails, phone calls, case review meetings, etc.)
• Support practice staff to develop creative processes to proactively manage patients with asthma and/or obesity in a non-stigmatizing manner; help practice staff to develop patient-centered care goals.
• Collaborate and communicate with interdisciplinary primary care team to identify care plan goals.

Additional Ad-hoc Responsibilities (generally on an as-needed basis):

• Attend initial and continuing education training programs, including self-directed reading and in-person and online learning.
• Complete an initial assessment with the patient and provider to identify the specific areas of focus for the asthma CHAMPION CHW role with particularly high-risk patients.
• QUALIFICATIONS:
• High school diploma or GED required.
• Relevant experience in the community or a bachelor's degree preferred; preference for Psychology/Social Work/Public Health or related field.
• 3 years of experience in the field, pediatric healthy weight management training, or experience and motivational interviewing training is desired.
• Position is grant-funded.
• Spanish and English language proficiency is required.

• Ability to identify problems, think creatively, and devise innovative solutions.
• Ability to work both independently and as a team member in multicultural settings.
• Ability to persuade, influence, and enlist others' support in accomplishing objectives.
• Ability to connect and engage with the Hispanic Community desirable.
• Proficient in Microsoft Applications, including MS Word and Excel.
• Strong time management, organizational, and planning skills; ability to multitask.
• Ability to work from home or an office-based environment.
• Regular travel to local and community-based primary care practices