BFT - Community Health Worker

Principal Duties and Responsibilities:

Patient Engagement and Assessment

• Provide community health work services including access to benefits and appropriate programs for patients in need.
• Support community resource finding related to SDOH needs, including food, housing, transportation, and other areas as needed.
• Work with patients and providers to set goals for patient care and motivate patients to meet their health goals.
• Work with the patient to identify and help to address barriers to care.
• Provide culturally sensitive services to patients from different cultures.
• Help the patient to put systems in place in their environment to assist with the management of their care.

On-Site Operations

• Spread awareness and offerings to prospective and current patients of MGB by engaging with the community in a retail setting.
• Coordinate with the provider and Walgreens staff to set up equipment and materials at the start of clinic hours and to close out each shift.
• Troubleshoot operations and equipment with Walgreens staff when necessary.
• Adapt to changes in store layout and/or clinic structure and maintain quality of care.
• Communicate with the Operations Manager and/or Medical Director when stock is low for materials and equipment.
• Provide feedback and offer solutions to operational workflow issues as arise.
• Be nimble and flexible to navigate isolated circumstances. Must be able to deal with ambiguity.

System Navigation, Health Coaching and Care Coordination

• Help to address any logistic barriers, scheduling complications, childcare needs, etc., that would prevent a patient from returning to the clinic for follow-up care.
• Assist patients in organizing their records, making follow-up appointments, and filling their prescriptions.
• Help patients develop their plans for getting to various appointments for screening and diagnostic tests, and treatment services.
• Provide education on specialty, imaging, or other appointments when needed for added support and advocacy.
• Follow up on key aspects of the patient's care to assess the in-home barriers to compliance and engage patients in addressing their barriers.

Collaboration and Documentation

• Maintain regular communication with the patient's providers through clinical messages in the electronic health record, emails, phone calls, and case review meetings.
• Document each patient encounter in detail. Track benchmarks of progress in care - including short-term goal completion along the way.
• Work with providers to reinforce health education messages - the importance of follow-up care, medication adherence, routines of self-care, etc.
• Refer to internal or external care management services when other issues are identified (i.e. food insecurity, domestic violence, etc.)
• Help patients fill out applications for community services such as Medical Assistance and SNAP (Supplemental Nutrition Assistance Program).
• Provide advocacy, patient education, and support in accessing community-based and hospital-based programs.
• Enter notes of intervention into the appropriate electronic health record.
• Work with medical interpreters to reach patients of other languages.
• Produce mid-year and end-of-the-year reports on program activities compiling data from databases and writing up case examples.

Qualifications:

• Preferred: prior experience as a community health worker, health coach, or outreach worker desired
• Required: High School Diploma or GED
• Candidate must be a local community resident with good knowledge of the resources available within the community
• A combination of education and experience may be substituted for requirements

Skills/Abilities/Competencies:

• Ability to perform client and community assessments; including, but not limited to: Social Determinants of Health screenings.
• Effective verbal, written, and technical communication skills. Ability to apply culturally based communication and care.
• Ability to carry out written and oral instructions.
• Ability to exercise appropriate judgement in the application of professional services.
• Ability to provide support, advocate for and coordinate care for clients.
• Ability to apply Public Health concepts and approaches.
• Self-motivated and possesses the ability to work both independently and as a team member in multicultural settings.
• Solid knowledge of the core competencies for SHWs, as identified by the Massachusetts Department of Public Health
• Knowledge of outreach methods and strategies
• Knowledge of special topics in community health