Community Health Worker II

Community Health Worker II-(3280881)

Description

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 on-going 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.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. 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 familiar
• Develops a keen understanding of primary care model for optimal, coordinated population health, while incorporating community health worker principles
• Provide culturally-sensitive services to patients with asthma and their families
• Identify 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 :

Additional Ad-hoc Responsibilities (generally on an as-needed basis) :

Skills / Abilities / Competencies Required

Working Conditions

Qualifications

Qualifications

EEO StatementMassachusetts General Hospital is an Equal Opportunity Employer.

Primary Location

: MA-Boston-MGH 125 Nashua

Work Locations

: MGH 125 Nashua125 Nashua StreetBoston02114

Job

: Health and Wellness

Organization

: Massachusetts General Hospital(MGH)

Schedule

: Full-timeStandard Hours : 40

Shift

: Day JobPosted Shift Description : 4 days a week in pediatric primary care practice and 1 day remote

Employee Status

: RegularRecruiting Department : MGH Performance Analysis & Improvement

Job Posting

: Mar 13, 2024