Community Health Worker II

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The General Hospital Corporation

Mass General Brigham relies on a wide range of professionals, including doctors, nurses, business people, tech experts, researchers, and systems analysts to advance our mission. As a not-for-profit, we support patient care, research, teaching, and community service, striving to provide exceptional care. We believe that high-performing teams drive groundbreaking medical discoveries and invite all applicants to join us and experience what it means to be part of Mass General Brigham.

Job Summary

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 Mass General 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 Health Care Center and MGH Revere Health Care 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.

Qualifications

Key Areas of Responsibility:

* 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.

Principle Duties and Responsibilities:

Patient Engagement and Health Coaching

* 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.

Systems Navigation and Care Coordination

* 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,…