The Massachusetts General Hospital Down Syndrome Program (MGH DSP) is a collaborative, multidisciplinary team serving people with Down syndrome of all ages and their families. We provide evidence-based clinical care, education, and cutting-edge research so that individuals with Down syndrome can reach their full potential.
The Down Syndrome Program is seeking a bilingual (English/Spanish) Community Health Worker to assist our patients with Down syndrome and their families with accessing benefits, navigating assistance programs, and advocating for services.
This is an 8 hour (one day) a week position. This position will be a combination of in-office and community based/in home work. The CHW will need ability to travel around greater Boston area when in-home support is needed. The office space is located at 125 Nashua Street, Boston, MA.
Working with direction from the DSP social services team, the successful candidate will:
- Provide community health work services including access to benefits and appropriate programs for patients in need.
- Support community resource finding related to SDOH needs, including food, housing, transportation, and other areas as needed.
- Work with patients and providers to set goals for patient care and motivate patients to meet their health goals.
- Work with the patient to identify and help to address barriers to care.
- Provide culturally sensitive services to patients from different cultures.
- Help the patient to put systems in place in their environment to assist with the management of their care.
- 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.
- Work with providers to reinforce health education messages – the importance of follow-up care, medication adherence, routines of self-care, etc.
- Refer to internal or external care management services when other issues are identified (i.e. food insecurity, domestic violence, etc.)
- Help patients fill out applications for community services such as Medical Assistance and SNAP (Supplemental Nutrition Assistance Program).
- Provide advocacy, patient education, and support in accessing community-based and hospital-based programs.
- Enter notes of intervention into the appropriate electronic health record.
- Work with medical interpreters to reach patients of other languages.
- Follow up on key aspects of the patient’s care to assess the in-home barriers to compliance and engage patients in addressing their barriers.
- Help to address any logistic barriers, scheduling complications, childcare needs, etc., that would prevent a patient from returning to the clinic for follow-up care.
- Assistance with system navigation re: applying for benefits and services, such as Dept of Developmental Services (DDS), Community Servings, obtain Releases of Information as needed.
- Advocacy, care coordination, system navigation between Early Intervention and our team re: developmental support and adequate services.
- Assist families with care coordination in scheduling ancillary appointments as needed.
- Assist families in applying for Applied Behavior Analysis, when indicated. Assisting families in accessing new resources and supports after receiving a diagnosis.
- Assist, identify, and apply for In-Home Behavior Therapy when behavior concerns at home are impacting day to day functioning. Assisting with service navigation for families that may need a higher level of support for access to behavioral health.
- Provide outreach to families that may need to be referred to DSP Educational Advocate.
- Screen for eligibility for MGB ACO resources and places referrals: Fresh Connect, SDH referral.
- Help families access resources related to Social Determinants of Health SDOH.
Minimum Requirements:
- Fluent in spoken and written Spanish and English
- Ability to perform client and community assessments; including, but not limited to: Social Determinants of Health screenings.
- Effective verbal, written, and technical communication skills. Ability to apply culturally based communication and care.
- Ability to carry out written and oral instructions.
- Ability to exercise appropriate judgement in the application of professional services.
- Ability to provide support, advocate for and coordinate care for clients.
- Ability to apply Public Health concepts and approaches.
- Self-motivated and possesses the ability to work both independently and as a team member in multicultural settings.
- Solid knowledge of the core competencies for SHWs, as identified by the Massachusetts Department of Public Health
- Knowledge of outreach methods and strategies
- Knowledge of special topics in community health
- Valid driver's license
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