Spanish Community Health Worker II - Community Health Program

Site: 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.

 

Seeking a Bilingual Spanish / English Candidate. Starting pay $25.86

 

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 of these goals. In addition, the asthma-lifestyle 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 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 Respon