Community Health Worker I

Massachusetts General Physicians’ Organization • Boston, MA, United States • $200k - $250k / year • 1m ago

Job Description - Community Health Worker I (3302048)

The Community Health Worker is a member of the health care team who utilizes their experience and cultural and linguistic knowledge to facilitate key components of patients' treatment. The community health worker will engage patients, create a trusting relationship, navigate patients to important appointments and resources, make follow-up home visits as needed and closely communicate with the provider team based on clear goals set out through the referral process. The community health worker will engage patients in setting their own short-term goals and will track the benchmarks along the way toward the achievement of these goals. The CHW will aid patients in the coordination and completion of appointments inside and outside of health center. In addition, the community health worker will work with patients to help decrease barriers to timely follow-up care. While the community health worker is not a clinical position, it requires a good knowledge (ability to learn) of basic concepts and an understanding of when a referral to a licensed clinician is appropriate.

PRINCIPAL DUTIES AND RESPONSIBILITIES:

Provide community health work services for patients identified by the integrated team for various Social Determinants of Health issues.
Engage in outreach efforts as determined by the Health Center to meet patients and community members "where they are".
Provide patient education that is culturally and linguistically appropriate.
Complete an initial assessment with the patient and provider to identify specific areas of focus for the CHW role.
Work with patients and providers to set goals for patient's care and motivate patients to meet their health goals.
Identify and help patients address barriers to care.
Provide culturally sensitive services to patients from different cultures.
Help patients put systems in place in their own environment to assist with the management of their care.
Address logistical barriers; scheduling complications, childcare needs, etc., that would prevent a patient from attending appointments.
Assist patients in organizing their records, making follow-up appointments, and filling their prescriptions.
Help patients develop their own plans for attending various appointments for screening and diagnostic tests, and treatment services.
Accompany patients to specialty and imaging centers when needed to provide support and advocacy.
Make regular home visits to follow up on key aspects of the patient's care, assess in-home barriers, and engage patients in addressing those barriers.
Maintain regular communication with the patient's providers through clinical messages in EPIC, emails, phone calls, and case review meetings.
Document each patient encounter in detail. Track benchmarks of progress in care, including short-term goal completion.
Work with primary care providers to reinforce health education messages, the importance of follow-up care, medication adherence, and self-care routines.
Refer to internal or external case management services when other issues are identified (i.e., hunger, domestic violence, etc.).
Provide advocacy, patient education, and support in accessing community-based and hospital-based programs.
Maintain HIPAA compliance and patient confidentiality.

QUALIFICATIONS:

BS in Social Work or related field preferred. High School degree required.
Minimum two years of working experience.
Previous work in community settings preferred.

SKILLS/ABILITIES/COMPETENCIES REQUIRED:

Demonstrated commitment to impacting the care of patients and communities.
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 multitask.
Proficient in all Microsoft Applications, including MS Office and Excel.
Strong time management, organizational, and planning skills.