What are the responsibilities and job description for the Community Health Worker II - Community Health Program position at Massachusetts General Hospital?
Key Areas of Responsibility:
- Works as an effective team member of the ECH 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
- Engage patients telephonically, via home visits, and in the PCP office with occasional accompaniment to medical appointments and community services.
*Facilitation of weekly group visit sessions with families (virtually and in-person), based on a set curriculum. CHWs will be responsible for reminder calls, conducting the visit, and all associated planning activities.
*Meet with patients 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.
- Work with patients and families to identify and help address barriers to care.Make home visits 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; identify environmental risk factors and triggers. Help the patient to put systems in place in their own environment to assist with self-management of care (i.e.: following up on appointments, prescription management)
*Provideculturally 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.
*Connect families with community organizations/activities that promote a healthy lifestyle.
*Phone call communication with families to support clinic expectations, attendance and goals.
*Other duties as necessary.
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 and/or join via telehealth.
*Assist patients in organizing their records, making follow up appointments, filling their prescriptions, 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.
*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
- Using patient registries, identify and monitor high-risk patients with medical and/or psychosocial conditions to provide community health services.
*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 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 CHW role with particularly high-risk patients.
.High school diploma or GED required.
. Relevant experience in the community orbachelor's degree preferred; preference for Psychology/Social Work/Public Health or related field.
. Three years of experience in the field, pediatric healthy weight management training or experience and motivational interviewing training is desired.
. Position is grant funded.
. English language proficiency is required.
Skills/Abilities/Competencies Required:
*Ability to identify problems, think creatively, and devise innovative solutions.
*Ability to persuade, influence and enlist others' support in accomplishing objectives.
*Spanish and/or other language fluency [Portuguese, Haitian Creole, Arabic] desirable.
*Ability to connect and engage with Black / African Community desirable.
*Strong time management, organizational and planning skills; ability to multi-task.
. Ability to work both independently and as a team member in multicultural settings.
. Proficient in Microsoft Applications, including MS Word and Excel.
The General Hospital Corporation is an Equal Opportunity Employer. By embracing diverse skills, perspectives and ideas, we choose to lead. All qualified applicants will receive consideration for employment without regard to race, color, religious creed, national origin, sex, age, gender identity, disability, sexual orientation, military service, genetic information, and/or other status protected under law. We will ensure that all individuals with a disability are provided a reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment.
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.
