Community Wellness Advocate

BMC Software•Boston, MA

7d•$23 - $32

About The Position

A Community Wellness Advocate (CWA) is a trusted community member who supports high-risk patients in maintaining stable health and wellness by connecting hospital, home-based, and community-based services. The CWA provides advocacy and case management, develops interdisciplinary care plans based on patient needs, facilitates access to social services and other resources, monitors progress, and helps patients overcome barriers to concrete supports. CWAs provide individual, family, and interdisciplinary group support in patients’ homes or community settings. They collaborate with the Patient Care Manager, primary care provider, and other care team members to assess needs and respond to barriers affecting health and wellness. The role includes outreach, education, goal setting, resource coordination, appointment support, documentation, and follow-up. CWAs do not provide hands-on care or services considered home health services, such as assessments, treatment, counseling, or monitoring a patient’s health status.

Requirements

High school diploma with community experience or a bachelor’s degree.
Valid driver’s license.
At least 2 years of prior healthcare, public health, or community-based experience in a community setting.
Basic knowledge of the healthcare system.
Strong interpersonal skills for interacting with patients and families.
Interest in community health and outreach.
Strong organizational skills and ability to multitask and work independently and as part of a team.
Demonstrated oral and written English communication skills.
Understanding of how language, culture, and socioeconomic circumstances affect health.
Desire to work with diverse, multicultural, and multilingual populations.
Proficiency with Microsoft Office applications, including Word, Excel, Access, and Outlook, and web browsers.
Proficiency with data entry and data tracking.

Nice To Haves

Fluency in Haitian Creole or Spanish.

Responsibilities

Initiate face-to-face contact with eligible patients, explain the CWA role and participation benefits, and begin screening.
Schedule and complete screening, care-plan, and follow-up visits or calls in hospital, clinic, home, and community settings within required timeframes.
Teach patients using culturally, linguistically, and educationally appropriate strategies.
Document activities, assessments, patient updates, and day-to-day data in the patient record and care management system, including Epic.
Participate in community outreach, presentations, development of materials, and phone calls with other staff.
Work with patients and providers to set care goals and guide patients toward achieving them.
Reinforce disease self-management education by connecting patients with community services and programs.
Present patients clearly and logically at case review meetings.
Consult with the Patient Care Manager, clinical staff, behavioral health teams, and/or PCPs about complex situations and incorporate provider feedback into care plans.
Collaborate with interdisciplinary care teams and connect patients to resources as needed.
Record and monitor participants’ progress toward goals within specified timeframes.
Prepare reports and documents as requested or needed.
Help patients organize records, schedule and attend follow-up appointments, and fill prescriptions.
Help patients complete applications, including applications for Medical Assistance, housing, and SNAP.
Provide advocacy, patient education, and warm handoffs to community-based and hospital-based programs.
Help patients address barriers by connecting them with supports such as healthcare services, behavioral health, financial assistance, childcare and caregiver support, housing, utility assistance, food, clothing, transportation, violence prevention, and social connection.
Coordinate with community-based long-term services and supports.
Provide intensive home- and community-based outreach, motivational interviewing, goal setting, resource connections, and accompaniment to medical appointments as needed.
Visit patients in hospital and emergency room settings as needed to support transitions of care.
Establish culturally appropriate, trusting relationships with patients and families.
Participate in training designated by the Community Wellness Manager and Nurse Practitioner, and attend scheduled supervision and program meetings.
Develop and maintain relationships with community organizations and resources to support patient access.