Community Health Worker I - Per Diem

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.

The Down Syndrome Program is a subspecialty service of the Division of Medical Genetics in the Department of Pediatrics (MassGeneral Hospital for Children) at Massachusetts General Hospital. This program offers specialized services for children, young adults, and adults with Down syndrome and their families.

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.

• 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