Community Health Worker II

Mass General Brigham•Chelsea, MA

14d•$20 - $29•Hybrid

About The Position

MGH strives to advance health equity, improve health outcomes, and promote the 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 MassGeneral Hospital for Children (MGHfC) and the Department of General Internal Medicine (DGIM) Population Health Management teams. MGHfC 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 Community Health Worker (CHW) will be part of the pediatric CHAMPION Program’s multi-disciplinary care team, which includes a physician and a 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 CHAMPION CHW will provide care to children and adolescents with overweight/obesity and asthma, through group and individual visits, both in-person and virtually, and will participate in a Virtual Learning Community and Quality Improvement calls and activities as part of the research project. The CHAMPION CHW will support this program at the MGH Chelsea HealthCare Center and MGH Revere HealthCare Center. Hours are expected to be roughly 10am-6:30pm Mondays, Tuesdays and Thursdays based on clinical schedules, and Wednesdays and Fridays, 8:30am-5pm. The CHAMPION 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 -Healthy Weight Lifestyle CHAMPION 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 the role is part of the clinical team and 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.

Requirements

High school diploma or GED required.
Relevant experience in the community or a bachelor’s degree preferred; preference for Psychology/Social Work/Public Health or related field.
3 years of experience in the field, pediatric healthy weight management training, or experience and motivational interviewing training is desired.
Position is grant-funded.
Spanish and English language proficiency is required.
Ability to identify problems, think creatively, and devise innovative solutions.
Ability to work both independently and as a team member in multicultural settings.
Ability to persuade, influence, and enlist others’ support in accomplishing objectives.
Proficient in Microsoft Applications, including MS Word and Excel.
Strong time management, organizational, and planning skills; ability to multitask.
Ability to work from home or an office-based environment.

Nice To Haves

Ability to connect and engage with the Hispanic Community desirable.

Responsibilities

Works as an effective team member of the MGHfC and DGIM population health management program to provide health coaching and care coordination to patients and families.
Meet with patients in person or virtually 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.
Connect families with community organizations/activities that promote a healthy lifestyle.
Phone call communication with families to support clinic expectations, attendance and goals.
Facilitation of weekly group visit sessions with families (virtually and in-person), based on a set curriculum.
CHAMPION CHW will be responsible for reminder calls, conducting the visit, and all associated planning activities.
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.
Other duties include keeping strong communication between the different components of the research, clinical, schedules and patient care.
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, and 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.
Support timely scheduling, communication, and problem-solving across areas to ensure program excellence.
Refer to internal or external case management services within the practice when other issues are identified (i.e., food insecurity, domestic violence issues, etc.)
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 and communicate with interdisciplinary primary care team to identify care plan goals.
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 CHAMPION CHW role with particularly high-risk patients.