Clinical Community Wellness Advocate

BMC Software • Arlington, MA

135d

About The Position

Boston Medical Center Health System (BMCHS) is a leading academic medical center with a deep commitment to health equity and a proud history of serving all who come to us for care. BMC provides high-quality healthcare and support, extending beyond our physical campus into our vibrant and diverse communities. As a core member of the Boston Medical Center Health System, BMC is advancing medicine and training the next generation of healthcare providers and researchers. In 2021 BMC launched the “Health Equity Accelerator” with the purpose of ‘transforming healthcare to deliver health justice and well-being’. The Accelerator, in partnership with Population Health, is developing an innovative multi-disciplinary approach that combines clinical operations, community engagement, health-related social needs programs, and research assets to address racial health inequities. The Community Wellness Advocate (CWA) is a trusted member of the community who helps promote and maintain stable health and wellness for patients and families through connections to program and community-based services. The CWA will serve as the patient’s guide throughout the program and is responsible for supporting patients in the management of their conditions (hypertension, diabetes, and obesity). This role will perform direct outreach to patients, families, and/or caregivers to provide culturally appropriate follow-up. CWAs will also partner with patients to identify and address any barriers or challenges that may prevent access to care and connect them with the appropriate care team members. A critical role of the CWA is to act as the liaison between the patient and the program care team. As the liaison, the CWA will help to distill medical information delivered from care team members down into digestible “plain language” to assist the patient in managing their condition. To manage this effectively, the CWA will need to build relationships with care team members to support patients’ health goals and priorities. The CWA will partner with the Community Health Equity Manager in identifying and developing programming to offer patients throughout the program around economic mobility and nutrition security. The CWA will play a critical part in population health management and patient navigation, contributing to the overall effectiveness of our program. This role requires strong communication skills, emotional intelligence, and a commitment to advancing health equity.

Requirements

• HS Diploma with community experiences required and minimum of 2 years prior in healthcare, public health, or community-based experience preferably working with adults
• Or equivalent combination of education and experience
• Bachelor's degree in a relevant field (social work, public health, etc.) preferred
• Phlebotomy certification or phlebotomy training program that meets the qualifications allowing blood draw in Massachusetts
• Multilingual skills in languages appropriate to the patient populations served by the medical center preferred (Spanish or Haitian Creole)
• Familiar with Mattapan community and surrounding zip codes
• Strong interest in social determinants of health and advancing racial health equity
• Outstanding interpersonal skills to interact with families and patients
• Basic knowledge of the healthcare system
• Interest in community health and outreach
• Exceptional organizational skills: ability to multi-task and work independently as well as part of a team
• Understanding of how language, culture, and socioeconomic circumstances affect health
• Knowledge of software applications such as Microsoft Office, and electronic medical record systems
• Ability to build and manage relationships in a highly complex and changing environment
• Demonstrated ability to handle stressful situations in a calm and professional manner
• Effective verbal and written communication skills appropriate to the patient populations served
• Physical ability to meet the core job responsibilities in accordance with practice setting demands

Responsibilities

• Care coordination and case management
• Manage a panel of patients engaged in various stages of the program
• Assess patients social, financial and family resources and connect patients to available program and community resources in partnership with the other program team members
• Use standardized questionnaires including (e.g., THRIVE and PAID-5) to identify social determinants of health (SDOH) and diabetes, hypertension, and obesity related distress
• Schedule and complete community-based visits (e.g., homes, community organizations, community spaces)
• Teach key educational messages using a variety of culturally, linguistically and educationally appropriate strategies in a variety of settings
• Work with patients and program care team to set goals for the patient’s care and provide guidance to the patient to achieve those goals
• Present patient cases during team huddles succinctly and logically
• Facilitate the flow of information between patient, provider and other program team members and distill medical information down into 'digestible plain language'
• Attend trainings and professional development opportunities to maintain knowledge of chronic disease management and available resources
• Serve as a central contact for patients navigating diabetes, hypertension, and obesity care in the program as part of the multidisciplinary care team
• Schedule appointments for patients, ensuring that they receive timely reminders and follow-up care
• Leverage Motivational Interviewing techniques or similar tools to engage patients and provide emotional support to patients and their families throughout the program
• Verify and update patient insurance information when scheduling any visits
• Proactively contact patients to resolve and follow-up on potential barriers for appointment completion
• Provide general clerical support including filing, making appointments, photocopying, faxing, preparing and sending mail, making reminder phone calls, and maintaining contacts database
• Facilitate distribution of patient’s remote monitoring devices
• Ensure patient’s remote monitoring data is flowing into the EMR and troubleshooting any issues that arise
• Provide and receive constructive feedback from team members and patients
• Document patient communication in the Electronic Medical Record (EMR) using encounter notes, inbasket messages and MyChart
• Develop and document barriers to care and plans for resource connections
• Document assessments and key patient updates in EPIC system
• Clearly document all activities in the patient’s record and care management system
• Attend regularly scheduled supervision and other program assigned meetings
• Maintain database of community-based resources in partnership with other program staff
• Attend group programming to build relationships with program patients and identify areas for support
• Participate with other staff in activities that include community outreach, presentations to community organizations, development of materials, and phone calls
• Partner with the Community Health Equity Manager to identify and develop community-based programming around economic mobility and nutrition security
• Reinforce educational messages regarding condition self-management by linking patients with support community-based services and programs
• Provide advocacy, patient education, and successful warm hand-offs in accessing community-based programs and coordinate long-term support beyond the program
• Develop and maintain strong relationships with the community and community resources to ensure patient access
• Assist with facilitation of community and patient listening sessions
• Contribute to the development of new ideas that impact the program
• Adapt to changes with departmental needs including but not limited to offering assistance to other team members, floating, adjusting assignments, etc.
• Conform to hospital standards of performance and conduct, including those pertaining to patient rights and HIPAA and privacy rules, so that the best possible customer service and patient care may be provided
• Utilize hospital’s behavioral standards as the basis for decision making and to support the department and the hospital’s mission and goals
• Follow established hospital infection control and safety procedures
• Perform other duties as assigned to support overall program priorities
• Perform venipunctures according to laboratory policies and procedures including the collection of timed specimens, blood cultures, pediatric and neonatal specimens
• Receive and prepare laboratory specimens prior to laboratory analysis and testing, including study specimens, random and 24 hour urines, and send-out specimens
• Positively identify all patients according to laboratory policies and procedures
• Verify identification of specimens and label specimens according to laboratory policies and procedures
• Centrifuge and aliquot specimens, and follow all special handling instructions according to laboratory policies and procedures
• Complete all laboratory and hospital safety, compliance, and competency training as assigned
• Follow established hospital infection control and safety procedures

Benefits

• Equal Opportunity Employer/Disabled/Veterans
• Working at Boston Medical Center is more than a job. It’s a chance to make a difference as part of our mission to provide exceptional and equitable care to all.
• BMC is dedicated to improving the health of our community in Boston and beyond.
• BMC’s mission to provide exceptional care without exception extends to our employees, and we have been recognized as a top employer and best place to work.
• A strong sense of teamwork and support for our staff are the bedrock of BMC, as we know that we can only provide exceptional care to patients when our staff are cared for too.

What This Job Offers

• Job Type: Full-time
• Education Level: High school or GED
• Number of Employees: 1,001-5,000 employees