Community Health Worker II - Community Health Program

Site: The General Hospital Corporation

 

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.

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.

 

 

Job Summary

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.

This position will contribute to these MGH efforts through collaboration with the Department of Equity and Community Health (ECH) and the Department of General Internal Medicine (DGIM) Population Health Management teams.

ECH 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 DGIM Population Health Management team develops and implements population-based efforts to monitor and improve clinical effectiveness through systems-based strategies and interventions. Its goal is to improve the quality and cost effectiveness of health care by informing clinical decision-making processes, changing patient and clinician behaviors, enhancing the care choices of physicians, other providers and patients, and optimizing care tools and systems.

The Community Health Worker (CHW) will be part of the pediatric CHAMPION Program’s multi-disciplinary care team which includes a physician and 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 CHW will provide case management for children and adolescents with overweight/obesity and asthma, through group and individual visits, both in-person and virtually. The CHW will support patient follow-up, goal completion, motivation, and connection to community-based organizations to support lifestyle change. The CHW will also participate in the Virtual Learning Community and Quality Improvement calls and activities, and will be responsible for clinical scheduling, reminder calls, telehealth technical assistance, and other visit management tasks.

Under the management of ECH and DGIM, the asthma-lifestyle CHW will participate in patient-centered, team-based care. S/he/they will support primary care physicians (PCPs) and practices in managing their panel of patients with asthma and/or obesity. S/he/they will incorporate the PCP’s clinical goals and family goals to identify plans of action. By gathering and organizing patient data from clinical registries and medical records, the asthma-lifestyle CHW works to identify patients’ unmet needs, engage patients in self-management, gather summary information for treatment interventions, and provide wrap-around support that traditionally falls outside of clinical care.

The CHW will engage patients and their families, develop a trusting relationship, help families to navigate the health system, make home visits to identify environmental influences and closely communicate with the clinical team based on clear clinical goals set out during the referral process. In addition, the 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