Community Health Worker - West at Commonwealth Care Alliance in Springfield, Massachusetts

Job Description:

Why This Role is Important to Us
Commonwealth Care Alliance's (CCA) iCMP Plus ACO inter-professional teams are responsible for providing primary care and care management to a specific panel of high risk, Medicaid ACO eligible, non CCA patients. This patient group is made up of individuals with significant medical, behavioral, and social complexities that require intensive case management. This cohort of patients belong to outside organizations that are contracted with CCA to provide this complex care. The iCMP Plus Health Outreach Worker (HOW) functions within and is an integral part of an inter-professional team. This team is responsible for the care coordination and care delivery of a panel of Medicaid ACO patients. The HOW will be responsible for locating and engaging through research to identify accurate contact information for Medicaid ACO patients. This individual works to overcome language, cultural and developmental barriers and engages caregivers and/or household members, as applicable. Also, ensures that Medicaid ACO patients overcome barriers to health associated with social determinants of health. The HOW has the opportunity to use evidence, knowledge of community based resources, trauma/recovery skills, and education to influence the clinical outcomes of iCMP Plus ACO patients by impacting acute care utilization, closing of quality gaps, and optimizing primary care, behavioral health care, and SUD services. The iCMP Plus HOW will play an integral role in support to patients that are frequent ED utilizers and are re-admitted with the goal of reducing ED and re-admissions. Engagement by the iCMP Plus HOW can occur in two different ways. - Episodic engagement is triggered by an acute event or significant change in condition of a patient which necessitates close, short term intervention by a HOW. - Longitudinal engagement is delivered to members who have significant SDOH needs and (through behavioral diagnosis, SUD, trauma, etc.) that require a long term relationship with the HOW. This position requires in person visits to members in their homes and the community across various locations in Massachusetts. The iCMP Plus HOW will report to the HOW Manager and a dotted line to the iCMP Plus Clinical Manager.

What We're Looking For
- Minimum Education Required - Associates Degree - Preferred Education- Bachelor's Degree - 3-5 years minimum experience in community-based care - 4+ years of minimum experience working in outreach or in the community with members who have high behavioral health needs and high medical complexity. - CHW Certified - Required: - Excellent written and verbal communication skills. - Working knowledge of Microsoft Office applications - Excellent organizational skills. - Ability to utilize an Electronic Medical Record - Ability to use on-line training platforms - Demonstrated understanding of Mass health benefits - Ability to review welcome packets and obtain consent forms - Demonstrated understanding of LTSS - English required, bilingual preferred - The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job - Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions - While performing the duties of this job, the employee is regularly required to stand; use hands to finger, handle, or feel; reach with hands and arms; and talk or hear - Specific vision abilities required by this job include close vision, distance vision, and ability to adjust focus




What You'll Be Doing
- Uses internal and external resources (such as referrals, chart review and pharmacy data) to identify accurate, successful modes of communication for initial patient engagement. - Outreach to and engage providers in research efforts, as needed. - Outreach directly to patients. - Utilizes communication skills such as motivational interviewing to gain agreement from the patient to participate and be receptive to the iCMP Plus Program. - Provides education to new patients regarding iCMP Plus and the role of the Care Partner and Care Team. - Maintains appropriate written and oral communication on a timely basis, completing documentation within 48 hours and returning non-urgent calls within 48 hours. - Will engage in regular assessments (HRA, LTSS) pertaining to Social Determinants of Health (SDOH). - Conduct regularly scheduled visits to ensure that patient's medical, behavioral and social needs are addressed. - Support the health education needs of the patient in collaboration with the Care Partner, Behavioral Health Specialist and PCP. - Works toward the promotion, prevention, and reduction of health risks. - Identify gaps pertaining to SDOH which influence barriers to patients care and influence unmet needs. - Coordinate with the Care Partner along with the PCP and iCMP Plus inter-professional care team to identify areas of opportunity, as well as defined resources. - Responsible for assessing health risks, completes health risk assessment (HRA). - Provide input to patients care team on key care management/care coordination decisions. - Coordinate appointments for patients with multiple services including PCP, specialists for both routine and acute visits. - Assess SDOH and provide psychosocial evaluations at member visits. - Support efforts to decrease hospital readmissions and high emergency department use. - Supports patients with Post Discharge follow up (Post Discharge Assessment) as needed and when requested by Care Partner. - Coordinate and contact with other care management resources the patient may be connected. - Support patients in re-aligning to ACO, MassHealth application and benefits. - Participate in weekly Interprofessional Care Team meetings. - Assist members in obtaining or stabilizing housing, finances, food, heating, educational/vocational opportunities (eg. DTA, housing applications, furniture applications ,fuel assistance, safelink phone, court visits, SSI applications) - Ensures appropriate documentation of visits and activities within EPIC system. - Addresses issues regarding substance misuse/ abuse, if indicated. - Uses recovery strategies such as motivational interviewing, harm reduction, positive behavioral support techniques, limit setting and strength based approaches to support patients in attaining goals. - Provides support and notifies Care Partner regarding changes in: behavior, nutrition, exercise, substance use, medication compliance, and other issues. - Provides 1:1 education to members regarding chronic disease self-management to prevent and manage health conditions and that encourages healthy behaviors and supports members in developing healthier habits. - Provides consultation and support to other members of the iCMP Plus Care Team.

Actual Work Location
101 Wason Avenue, Springfield, Massachusetts 01107

All Locations
CCA West - Wason Ave.; Main Street-Springfield

Exempt / Not Exempt
Non-Exempt