Community Wellness Advocate

BMC Software•Boston, MA

3d•$23 - $32

About The Position

A Community Wellness Advocate (CWA) is a trusted community member who helps high-risk patients maintain 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 identified needs, facilitates access to social services and other resources, monitors progress, and helps patients overcome barriers to concrete supports. The role provides one-on-one, family, and/or interdisciplinary group support in homes and community settings, collaborating with the Patient Care Manager, PCP, and other care team members to assess needs and respond to barriers to health and wellness. The CWA conducts patient outreach, screenings, care-plan and follow-up visits, education, resource connections, and care-transition support. The position documents patient activities and progress, participates in case reviews and team meetings, and maintains relationships with community organizations and resources. The CWA does not provide hands-on care or other home health services, such as performance assessments, care, treatment, counseling, or health-status monitoring.

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.
Exceptional organizational skills and ability to multitask, work independently, and work 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 role and benefits of participation, and begin screening.
Schedule and complete initial screenings, care plans, follow-up visits, and phone calls in hospital, clinic, home, shelter, housing-agency, substance-use-treatment, and other community settings within specified timeframes.
Teach educational messages using culturally, linguistically, and educationally appropriate strategies.
Document activities, assessments, patient updates, and data in patient records and care management systems, including Epic; prepare reports and other documents as needed.
Participate in community outreach, presentations, material development, and related calls.
Work with patients and providers to set care goals and guide patients toward achieving them.
Reinforce disease self-management education by connecting patients with supportive community services and programs.
Present patients clearly at case review meetings and consult with the Patient Care Manager, clinical staff, behavioral health teams, and/or PCP on complex situations and care planning.
Work within an interdisciplinary team and connect patients with resources as needed.
Record and monitor participant progress toward goals within specified timeframes.
Help patients organize records, make and attend follow-up appointments, and fill prescriptions.
Help patients complete applications, such as those for Medical Assistance, housing, and SNAP.
Provide advocacy, patient education, and warm handoffs to community-based and hospital-based programs.
Help patients address barriers using appropriate concrete supports, including healthcare and behavioral health services, financial assistance, childcare and caregiver support, housing, utilities, food, entitlements, clothing, transportation, violence prevention, and social connection resources.
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 trusting, culturally appropriate relationships with patients and families.
Participate in training designated by the Community Wellness Manager and Nurse Practitioner, and attend scheduled supervision and other program meetings.
Develop and maintain relationships with community organizations and resources to support patient access.