GENERAL SUMMARY/ OVERVIEW STATEMENT:
MGH strives to advance health equity, improve health outcomes, and promote well-being of our primary care patients by addressing health-related social needs, system navigation, and care coordination as standard of care. Community Health Workers (CHWs) are an integral part of achieving these goals.
CHWs build trust with their patients and help them to improve access and coordinate their health care. CHWs have the skills and experience to understand their patients' circumstances. By walking alongside their patients, CHWs help to address medical and psychosocial needs in order to promote self-efficacy, help patients meet their goals, and improve health outcomes.
CHWs use their unique skills (motivational interviewing, trauma sensitive care, coacing, etc.) to help patients manage their chronic diseases, adhere to medications, connect to community resources and gain strength and confidence in managing their own health. In addition, the community health worker will work with patients to help decrease barriers to timely follow-up care in the midst of challenging social, environmental and economic situations. The CHW will aid patients in the coordination and completion of appointments inside and outside of MGH. CHWs will work with patients to alleviate social determinants of health as well as improving their overall health and well-being. While the community health worker is not a clinical position, it requires a good knowledge (ability to learn) of basic clinical concepts and an understanding of when a referral to a licensed clinician is appropriate.
PRINCIPAL DUTIES AND RESPONSIBILITIES:
Patient Engagement and Assessment
Provide community health work services for patients identified as at-risk due to medical or psychosocial challenges.
Complete an assessment with the patient and provider to identify the specific areas of focus for the CHW work with particular at-risk patients.
Engage with patient, build trust and identify patient's barriers. Work with patients and providers to set goals for patient's care.
Educate, motivate and guide patients to meet their health goals.
Provide culturally sensitive services to patients from different cultures.
Help the patient to put systems in place in their own environment to assist with the management of their care.
Produce mid-year and end of the year reports on program activities compiling data from data bases and writing up case examples. Enter notes of intervention into the appropriate electronic health record
Collaboration and Documentation
Maintain regular communication with the patient's providers through clinical messages in the electronic health record, emails, phone calls and case review meetings. Document each patient encounter in detail. Track benchmarks of progress in care - including short term goal completion along the way.
System Navigation, Health Coaching and Care Coordination
Help to address any logistic barriers, scheduling complications, childcare needs, etc., that would prevent a patient from showing up at their appointment. Assist patients in organizing their records, making follow up appointments and filling their prescriptions. Help patients to develop their own plans for getting to various appointments for screening and diagnostic tests, and treatment services. Accompany patients to specialty and imaging centers when needed to provide support and advocacy. Meet patients in the community or in a safe outdoor space to conduct visits when and where appropriate to follow up on key aspects of the patient's care and to assess the in-home barriers to compliance. Work with primary care providers to reinforce health education messages - the importance of follow-up care, medication adherence, routines of self-care, etc. Review and educate patients on the preparation for colonoscopy, pap smear, mammogram, and other visits to specialty or imaging departments. Refer to internal or external case management services when other issues are identified (i.e. hunger issues, domestic violence issues, etc.) Provide advocacy, patient education and support in accessing community-based and hospital-based programs. Develop and maintain a strong working relationship with the schedulers of screening appointments Work with medical interpreters to reach patients of other languages.
The community health worker position requires the ability to be self-directing, outgoing, professional, organized and to work as a patient advocate with people from many different cultures and backgrounds.
SKILLS/ ABILITIES/ COMPETENCIES REQUIRED:
BS in Psychology/Social Work/Education/Public Health or related field preferred. High school degree required.
Minimum two years of working experience. Previous work in community settings and/or medical settings preferred.
Demonstrated ability to work effectively and provide advocacy for racial and ethnically diverse populations and communities.
Strong commitment to social justice and health equity.
Demonstrated commitment to impacting the care of at-risk patients.
Experience working as a patient navigator/community health worker preferred.
Ability to work both independently and as a team member in multicultural settings.
Detail-oriented with the ability to multi-task.
Strong oral and written communication skills.
Proficient in all Microsoft Applications, including MS Office and Excel.
Strong time management, organizational and planning skills.
Need to be able to work from home, in the community and in the office.
Partners Healthcare System