Community Health Worker

3 weeks ago

Boston, United States Commonwealth Care Alliance Full time

**Why This Role is Important to Us**:
The Community Health Worker (CHW) is responsible for supporting social determinants of health (SDOH) needs for a panel of individuals in the context of a member-led plan of care. The CHW will utilize evidence-based resources, knowledge of community-based care and supports, trauma/recovery skills, and health coaching/education to connect members with community supports. The CHW will help the member to access the best types of care for their needs including community long-term services and supports. They will focus on reducing gaps in preventive care interventions, optimize members' engagement with primary care, behavioral health, and substance use services. The CHW will play an integral role supporting members with frequent utilization of Emergency Departments and acute admissions with the goal of identifying SDOH factors that may be contributing, and partnering with the member to identify more efficacious and appropriate supports that empower the member and meet his/her needs. Massachusetts Community Health Worker reports to the CHW Manager.

**Supervision Exercised**: None

**What You'll Be Doing**:

- As an integral part of an Interprofessional Care Team and based on the fluctuating needs of a defined panel of members, the Community Health Worker will engage in regular assessments pertaining to Social Determinants of Health, visit and/or outreach members telephonically at regularly scheduled intervals, and conduct urgent follow-ups to ensure that members' Plan of Care is fully comprehensive and addresses significant medical, behavioral, and social needs. The CHW works toward the promotion, prevention, and reduction of health risks. The CHW will support the health education needs of the member in collaboration with the Interprofessional Care Team and PCP.
- The Community Health Worker will assess health risks and identify gaps pertaining to SDOH which create barriers to member's care and contribute to unmet needs. The Community Health Worker will coordinate with the Care Partner and the member's PCP (Primary Care Provider), as well as CCA's interprofessional clinical care team to identify areas of opportunity, as well as defined resources, and will work in coordination with the team to implement the care plan. In collaboration with the member, the CHW will take ownership of SDOH goals in the member's care plan and will provide input and support for key care management or coordination decisions. The CCA CHW:

- Facilitates and/or delivers preventative care and health coaching to members according to guidelines set by CCA Clinical Leadership
- Identifies and initiates a member agreed-upon plan to resolve areas of opportunity to meet quality metrics
- Assesses members' social determinants of health (SDOH), and provides support, further evaluation, or coaching as needed to support members in prioritizing their needs and goals
- Supports efforts to decrease hospital readmissions and high emergency department use
- Supports member retention and connection to Medicaid benefits
- Provides Diabetes Basics or other health coaching/education to members, as appropriate to support members' goals and care plan
- Supports health education to members on key quality metrics, including preventive care/screenings
- Participates in weekly Interprofessional Care Team meetings, as well as ad hoc case conferences when needed
- Participates in Root Cause Analysis (RCA) as needed
- Assists members in obtaining or stabilizing housing, finances, food, utilities, educational/vocational opportunities, and community supports
- Liaises with CCA Care Partner and community-based PCPs/ Specialists as needed.
- Engages with community agencies and service providers to build relationships to support membership
- Ensures accurate and complete documentation of visits and activities within CCA's central medical record and within the record of partners as indicated
- Addresses issues regarding substance misuse/abuse, if indicated, in conjunction with Behavioral Health Clinicians and supports
- Uses recovery strategies such as motivational interviewing, harm reduction, positive behavioral support techniques, limit setting, and strengths-based approaches to support members in attaining stated goals
- Provides support and notifies Care Partner regarding changes in behavior, nutrition, exercise, substance use, medication compliance, housing/resource stability, and other issues as related to the established care plan
- Provides 1:1 health education to members regarding chronic disease self-management to prevent and manage health conditions and encourage development of healthy behaviors/habits
- Provides consultation and support to other members of CCA Care Team
- Maintains appropriate written and oral communication on a timely basis, completing documentation within 24 hours of activity, and returning non-urgent calls within 48 hours
- Actively participates in the evaluation of own performance and progress
- Partic

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