Community Health Worker - NSPG Care Management Program at North Shore Physicians Group(NSPG) in Peabody, Massachusetts

Job Description:

This is a full-time position for someone interested in helping patients with complex medical and social problems improve their access and utilization of health care services.

A Community Health Worker (CHW) is a trusted member of the community who helps patients better access and coordinate their health care. We believe that CHWs have the skills and experience to understand what patients are going through and help them get through difficult times. CHWs are people who come from the communities they serve. CHWs act as caring neighbors to help patients address the social and medical problems that lead to poor health. The goal of a high risk community health worker is to assist the high risk patients with the tasks of getting medical care, working on health goals (such as arranging care, filling medication prescriptions, planning healthy meals, or finding time to exercise), and to help them deal with the real-life issues that keep them from staying healthy. Although a CHW is not in a clinical role, having the capacity to learn basic clinical concepts in order to identify when a referral to a licensed clinician is appropriate is an important skill.

The CHW will work with high risk patients receiving care at NSPG/NSHC. This high-risk patient population presents a unique set of challenges, including higher rates of mental illness and substance abuse. These patients are also often harder to contact and engage, as well as having weaker ties to their primary care practice. Many of these patients visit their local emergency department instead of their primary care doctor and receive fragmented care. Our project aims to integrate CHWs into the primary care team, serving as a bridge between the primary care team and patients in the community that are at high risk but are disconnected with primary care. By doing so we hope to re-engage patients with their primary care team and improve their patient experience and health outcomes. As a CHW on this project, you will develop trusting working relationships with the patients you work with and be supported by a primary care team that includes primary care physicians, care coordinators, and social workers.
RESPONSIBILITIES:
Provide community health work services for patients identified as high risk due to medical and/or psychosocial challenges.
Attend initial and continuing education training programs including self-directed reading and in-person and online learning.
Work with patient and provider to set goals for patients care.
Meet patients in their homes and community to perform structured assessments that include goal setting.
Meet patients in the emergency department, primary care clinic or hospital to reinforce and advance patient goals.
Make weekly follow-up calls and regular home visits to patients as appropriate.
Motivate patients to meet their health goals.
Provide culturally sensitive services to patients from different cultures.
Coordinate with the iCMP Resource Specialists to access resources for identified problems including homelessness, substance abuse and food insecurity after assessment by a licensed social worker clinician. iCMP is Partners HealthCares Integrated Care Management Program, a longitudinal, primary care-embedded care management program for high risk patients.
Assist patients with organizing their medical care needs such as making follow-up appointments, and filling their prescriptions.
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.
Refer to internal or external care management services when other issues are identified (i.e. food insecurity, domestic violence, etc.)
Develop and maintain strong working relationships with the iCMP nurse care coordinator, iCMP behavioral resource specialist, primary care physician and community behavioral health team.
Document each patient encounter in detail.
Prepare reports and documents as needed or requested.
Attend a weekly group meeting with program supervisors.
Other duties as reasonably assigned.

Bachelor's Degree Preferred

Partners HealthCare is an Equal Opportunity Employer & by embracing diverse skills, perspectives and ideas, we choose to lead. All qualified applicants will receive consideration for employment without regard to race, color, religious creed, national origin, sex, age, gender identity, disability, sexual orientation, military service, genetic information, and/or other status protected under law.