Community Health Worker II- Care Coordinator/ MGH- ICMP!

Site: The General Hospital Corporation<p><br/> </p><p>At Mass General Brigham, we know it takes a surprising range of talented professionals to advance our mission—from doctors, nurses, business people and tech experts, to dedicated researchers and systems analysts. As a not-for-profit organization, Mass General Brigham is committed to supporting patient care, research, teaching, and service to the community.  We place great value on being a diverse, equitable and inclusive organization as we aim to reflect the diversity of the patients we serve.</p><p></p><p>At Mass General Brigham, we believe a diverse set of backgrounds and lived experiences makes us stronger by challenging our assumptions with new perspectives that can drive revolutionary discoveries in medical innovations in research and patient care. Therefore, we invite and welcome applicants from traditionally underrepresented groups in healthcare — people of color, people with disabilities, LGBTQ community, and/or gender expansive, first and second-generation immigrants, veterans, and people from different socioeconomic backgrounds – to apply.</p><p><br/> </p><p><br/> </p><p><u><b>Job Summary</b></u></p>MGH strives to advance health equity, improve health outcomes, and promote well-being of our primary care patients by addressing health-related social needs, system navigation, and care coordination as standard of care. Community Health Workers (CHWs) are an integral part of achieving these goals. CHWs are trusted members of the community who help patients improve access and coordinate their health care. CHWs have 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.<br/><br/>The CHW Care Coordinator is part of the Integrated Care Management Program (iCMP) team at MGH. The iCMP is a primary care-based care coordination program. It is an innovative program that focuses on improving the health of high-risk medically, psychiatrically, and/or psychosocially complex adult patients. The objectives are to improve quality of care, patient and provider satisfaction, and reduction in overall healthcare costs. This is accomplished through proactive patient outreach, engagement, and care coordination. The CHW role collaborates closely with the interdisciplinary care team to connect patients to resources, improve patients’ access to care, and support patients to achieve optimal health and wellbeing. The position requires a high degree of flexibility, independence and willingness to participate in multiple activities and provide support to all members of the iCMP team.<p><br/> </p><p><u><b>Qualifications</b></u></p><p><span><b>PRINCIPAL DUTIES AND RESPONSIBILITIES:</b></span></p><p><span><b>Patient Engagement and Assessment</b></span></p><ul><li><p><span>Engage high-risk patients identified for CHW case management telephonically, within MGH, and/or at offsite locations as needed to advance care (community and/or home visit).</span></p></li><li><p><span>Conduct a<span> </span><span>comprehensive<span> </span></span>high risk assessement and utilize motivational interviewing to help patients identify their own health goals, support adherence to care plans, and identify and address barriers to medical care.</span></p></li><li><p><span>Collaborate with interdisciplinary primary care team to identify and complete care plan goals over the course of 1-3years. </span></p></li><li><p><span>Provide culturally sensitive services to patients from diverse racial, cultural, and socioeconomic backgrounds; utilize medical interpretation as needed.</span></p></li></ul><p><span><span><b>Systems Navigation, Health Coaching, and Care Coordination</b></span></span></p><ul><li><p><span>Provide <span>targeted interventions to a panel of identified patients to help address medical needs and social determinants of health (SDOH) that play a critical role in health outcomes.</span></span></p></li><li><p><span>Assist patients to navigate healthcare system, including helping patients schedule, obtain transportation, and attend appointments; accompany patients to appointments as needed.</span></p></li><li><p><span>Research and connect patients to community resources related to SDOH needs, including food, housing, transportation, legal services, and other identified needs.</span></p></li><li><p><span>Provide health coaching to support patients to address chronic illness and adopt healthy behaviors to assist with the management of chronic disease.</span></p></li></ul><p><span><b>Collaboration and Documentation</b></span></p><ul><li><p><span>Document care within the patient's electronic medical record.</span></p></li><li><p><span>Collaborate and communicate with iCMP and patient care team via email, telephone, and case conferences.</span></p></li></ul><p><br/> </