GENERAL SUMMARY/ OVERVIEW STATEMENT:
Mass General Brigham Neurology is participating in the Mass General Brigham United Against Racism initiative. We believe that systemic racism is a public health issue which impacts our patients, workforce, and the communities we serve. Working collectively, we are acting across the system to dismantle racism and learning as we go. Our mission is to dismantle the barriers, systems, and actions inside and outside our walls to provide excellent medical care and equity for all.
Work will begin through the project "A Community Health Worker Intervention to Support Acute Ischemic Stroke Survivors Who Reside in Marginalized Communities across Greater Boston". Stroke is the third cause of death and leading cause of disability in the United States. While MGB has achieved longstanding recognition for stroke care excellence, our team acknowledges that this work occurs in the context of a segregated society which perpetuates health inequity and injustice. Racial and socioeconomic disparities are extensively documented across the continuum of stroke prevention, diagnosis, care, and clinical outcomes. Our team is tackling the structural barriers to post-stroke treatment adherence faced by acute ischemic stroke survivors (AISS) from marginalized communities, as there is evidence that disparities in post-stroke treatment adherence threaten patients' clinical outcomes. We are inspired by effective community health worker (CHW) interventions that have eliminated disparities at and beyond MGB.
The CHW will engage with AISS in partnership with their clinicians and loved ones to better access and coordinate their health care with the goal of reducing their risk of recurrent stroke or death. Utilize skills and experience to understand what patients are going through and help them get through difficult times. Apply direct knowledge of the communities they serve. Act as a caring neighbor to help patients address the social and medical problems that lead to poor health. Work with AISS survivors identified by the neurology team due to social needs. Meet eligible AISS patients during their AIS hospitalization and work on creating a trusting relationship with them and their loved ones to support them on addressing social determinant of health needs such as food, housing, transportation, and connecting them to resources. The CHW will work to engage patients on adhering to key components of their health care. Some of these areas may include navigating patients to important appointments, and closely communicating with the clinical team based on clear goals set out through the referral process. Engage AISS and their loved ones in setting their own short-term goals and track the benchmarks along the way toward the achievement of these goals. Aid AISS in the coordination and completion of appointments connected to their stroke care. In addition, work with patients to help decrease barriers to timely follow-up care. While the CHW is not a clinical position, it requires knowledge (and ability to learn) of basic clinical concepts and an understanding of when a referral to a licensed clinician is appropriate.
PRINCIPAL DUTIES AND RESPONSIBILITIES:

• Provide CHW services for AISS identified due to socioeconomic challenges, including short term intensive case management and psychosocial support as needed to enable patients to access appropriate services, benefits, and programs.
• Support community resource finding related to SDOH needs, including food, housing, transportation, and other areas as needed.
• Work with patients, their loved ones, and clinical teams to set goals for patient's care and motivate patients to meet their health goals.
• Work with patients to identify and help to address barriers to care.
• Provide culturally and linguistically appropriate services to patients and their loved ones.
• Help patients and their loved ones to put systems in place in their own environment to assist with the management of their care.
• Help to address any logistic barriers (such as scheduling complications, childcare needs, and transportation) that would prevent a patient from participating in their appointment.
• Help patients to develop their own plans for getting to various appointments for screening and diagnostic tests, and treatment services.
• Provide education and accompany patients to specialty, imaging, or other appointments when needed to provide support and advocacy.
• Meet patients by phone, video, or in the community when and where appropriate to follow up on key aspects of the patient's care and to assess the in-home barriers to compliance and engage patients in addressing their barriers.
• Assist patients in organizing their records, making follow up appointments and filling their prescriptions.
• Maintain regular communication with the patient's clinicians through clinical messages in the electronic health record, emails, phone calls and case review meetings.

• Document each patient encounter in detail, including entering notes of intervention into the appropriate electronic health record. Track benchmarks of progress in care - including short term goal completion along the way.

• Work with clinicians to reinforce 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.
• Refer to internal or external care management services when other issues are identified (food insecurity, domestic violence, etc.)
• Help patients fill out applications for community services such as Medical Assistance and SNAP (Supplemental Nutrition Assistance Program).

• Develop and maintain a strong working relationship with the schedulers of screening appointments.
• Work with professional medical interpreters to reach patients across language differences.
• Produce monthly, quarterly, and end of the year reports on program activities compiling data from data bases and writing up case examples.
• Attend initial and continuing education training programs including self-directed reading and in-person and online learning.
• Perform other work as assigned, including attending meetings and participating in process improvement.

Qualifications
QUALIFICATIONS:

• High school diploma or equivalent required.
• Experience working as a patient navigator/community health worker preferred.

• Relevant work experience in the community.
• Previous work in community settings preferred.

SKILLS/ ABILITIES/ COMPETENCIES REQUIRED:

• Understanding of the needs of underserved patient, resources available and ability to coordinate services among those resources to benefit each patient
• Able to effectively communicate clinical, administrative, insurance and other information to patients, especially with limited experience within the healthcare system
• Understanding of insurance and related coverages
• Demonstrated commitment to impacting the care of high-risk patients as well as to advancing equity and justice in healthcare
• Demonstrate cultural competence and understanding of patient and family experiences with healthcare; able to effectively guide and assist with medical encounters in support of patients
• Maintain sensitive and confidential information
• Compliant with all policies and procedures, including HIPAA
• Ability to work both independently and as a team member in cross-cultural settings.
• Detail-oriented with the ability to multi-task.
• Proficient in all Microsoft Applications, including MS Office and Excel. Use of EPIC preferred.
• Strong time management, organizational and planning skills.

WORKING CONDITIONS:
Hybrid work environment. On-site work will occur in an office setting and in clinical areas.
Community based work may create exposures to other office and home settings as well as various forms of transportation.
Physical requirements such as prolonged sitting, riding on public or other transportation, walking required. Exposure to the natural environment on occasion.
Position may require hours outside of regular work schedule.
Valid MA driver's license to attend off-site meetings, training and patient appointment helpful.
EEO Statement
Massachusetts General Hospital is an EqualOpportunity Employer. By embracing diverse skills,perspectives and ideas, we choose to lead. Applications from protectedveterans and individuals with disabilities are strongly encouragedPartner's Healthcare is acting as an Employment Agency in relation to this vacancy.