Community Health Worker II - Community Health Program

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) and the Department of General Internal Medicine (DGIM) Population Health Management teams.

ECH oversees a team of Community Health Workers. 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.

The Community Health Worker (CHW) will be part of the pediatric CHAMPION Program's multi-disciplinary care team which includes a physician and dietitian. The evidence-based CHAMPION program and research study seeks to evaluate whether telehealth vs. in-person delivery of CHAMPION is equally effective at reducing child BMI and asthma control in diverse lower income families. The CHAMPION program consists of individual and group visits guided by a set curriculum with a multi-disciplinary team (medical provider, dietitian, and community health worker), and other tools to support behavioral change and reduce body mass index (BMI) and asthma, such as follow-up phone calls, educational materials, social determinants of health screening and referral and text messaging. The CHW will provide case management for children and adolescents with overweight/obesity and asthma, through group and individual visits, both in-person and virtually. The CHW will support patient follow-up, goal completion, motivation, and connection to community-based organizations to support lifestyle change. The CHW will also participate in the Virtual Learning Community and Quality Improvement calls and activities, and will be responsible for clinical scheduling, reminder calls, telehealth technical assistance, and other visit management tasks.

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 obesity. 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. 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. In addition, 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.

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)

* Provide culturally 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 or bachelor'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.