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.
This position will contribute to these MGH efforts through collaboration with the Department of Equity and Community Health (ECH), the Department of General Internal Medicine Population Health Management (DGIMPHM), and Department of Pediatrics teams.
CHWs are trusted members of the community with the skills and experience to understand their patients’ circumstances. By building trusting relationships and walking alongside their patients, CHWs help address medical and psychosocial needs in order to promote self-efficacy, help patients meet their goals, and improve health outcomes.
The DGIM Population Health Management team develops and implements population-based efforts to monitor and improve clinical effectiveness through systems-based strategies and interventions. Its goal is to improve the quality and cost effectiveness of health care by informing clinical decision-making processes, changing patient and clinician behaviors, enhancing the care choices of physicians, other providers and patients, and optimizing care tools and systems.
Under the management of ECH and DGIM, the asthma-lifestyle CHW will participate in patient-centered, team-based care. S/he/they will support primary care physicians (PCPs) and practices in managing their panel of patients with asthma and/or weight management issues. S/he/they will incorporate the PCP’s clinical goals and family goals to identify plans of action. By gathering and organizing patient data from clinical registries and medical records, the asthma-lifestyle CHW works to identify patients’ unmet needs, engage patients in self-management, gather summary information for treatment interventions, and provide wrap-around support that traditionally falls outside of clinical care.
The CHW will engage patients and their families, develop a trusting relationship, help families to navigate the health system, make home visits to identify environmental influences and closely communicate with the clinical team based on clear clinical goals set out during the referral process and ongoing clinical team communication. In addition, the CHW will engage patients and their families in setting their own short-term goals and will track the benchmarks along the way toward the achievement of these goals. The asthma-lifestyle CHW will work with patients to help decrease barriers to timely follow-up care and provide coaching to engage patients and families in identification and achievement of care goals.
This is not a clinical position but requires a good knowledge of (and willingness to learn) basic clinical concepts and an understanding of when a referral to a licensed clinician is appropriate. Protocols and ongoing training are in place to help facilitate the growth of this knowledge.
Key Areas of Responsibility:
- Works as an effective team member of the pediatric practice, ECH and DGIM population health management program to provide health coaching and care coordination to patients and families.
- Develops a keen understanding of primary care model for optimal, coordinated population health, while incorporating community health worker principles.
- Provides culturally-sensitive services to patients with asthma and their families.
- Identifies and assists with health-related social needs including needs related to food and housing insecurity, challenges with insurance, medication access, transportation, etc.
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.
- Support patients and families in setting and following through with clinical goals to manage their asthma and lifestyle goals to address how their weight is impacting their health.
- 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).
- Provide culturally sensitive services to patients from diverse racial, cultural, and socioeconomic backgrounds; utilize medical interpretation as needed.
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.
- Assist patients in organizing their records, making follow up appointments, filling their prescriptions, understanding past medical history.
- Work with primary care providers and pertinent specialists 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.
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 Latino/Black/African Community desirable.
- Proficient in Microsoft Applications, including MS Word and Excel.
- Strong time management, organizational and planning skills; ability to multi-task.
- Ability to work both independently and as a team member in multicultural settings.
Working Conditions
- Position requires in-person work at the Primary Care Clinic a minimum of 4 days a week (days in clinic site specific) with option to work remotely 1 day a week.
- Ability to work from home or Office-based environment.
- Regular travel to local and community-based primary care practices.
- Local travel to patient homes.
Qualifications
- High school diploma or GED required.
- Relevant experience in the community or Bachelor’s degree preferred; preference for Psychology/Social Work/Public Health or related field.
- Minimum 2 years of working experience. Previous work in community settings or promoting healthcare behavior change is preferred (i.e.: patient navigator/community health worker).
