Community Health Worker in Boston, Massachusetts

Community Health Worker

Mass General Brigham seeks a full-time Community Health Worker to work in the Bridges to Moms Program, helping to address gaps in social determinants of health for Obstetrics patients who are homeless or facing imminent homelessness, and providing long-term follow-up and care coordination through the baby's first year.

The Community Health Worker is a vital role within Brigham and Women's. A CHW is a trusted member of the community who supports patients to better access and coordinate their health care. In partnership with patients, CHWs have the skills and experience to navigate resources and support patients get through difficult experiences. CHWs come from the communities they serve and act as an extension of caring neighbors to help patients meet their social and medical needs which can lead to better health outcomes.

The CHW dedicates her/his time to establishing a trusting relationship with patients to address social determinant of health (SDOH) needs such as food, housing, transportation, and connecting them to resources. In addition, the CHW works with patients to help decrease barriers to connecting to primary care in order to ensure long-term access to care. While the Community Health Worker is not a clinical position, it requires knowledge of (ability to learn) basic clinical concepts and an understanding of how primary and social care teams work together to achieve best possible health outcomes.

Principal duties and responsibilities include:

• Providing community health services for pregnant and postpartum patients in the Bridges to Moms Program, including short-term intensive case management and in-person support as needed to advocate for appropriate services, benefits, and programs.
• Supporting closing gaps in community resources related to Social Determinants of Health (SDOH) needs, including assistance with housing and/or emergency shelter applications, food, transportation, utilities, medication costs, childcare, and health education needs.
• Working in partnership with the patient to identify and address barriers to care.
• Collaborating with patients and providers to set goals for the patient's care and motivate patients to meet their health goals. Document and track progress accordingly.
• Providing culturally sensitive and responsive services to patients from diverse cultures and communities.
• Supporting the patient to further develop systems within their environment to assist with the overall management of their care.
• Co-developing strategies to reduce logistic barriers to care, such as, scheduling conflicts, childcare needs, and transportation that would prevent a patient from attending appointments, tests, treatment, etc.
• Assisting patients in organizing their records, making follow-up appointments, and filling their prescriptions as needed.
• Accompanying patients to appointments when needed to provide support and advocacy.
• Identifying patient strengths to manage their own care.
• Meeting patients in the community or conducting "porch" visits when and where appropriate to follow up on key aspects of the patient's care, assess barriers within the home and identify potential solutions.
• Maintaining regular communication with the patient's provider and provider's care teams through health record database, emails, phone calls and case review meetings.
• Following documentation guidelines and protocol within health record database and other areas as assigned and determined by BTM Director and Program Manager.
• Working with BTM Director to refer to internal or external care management services when additional capacity is required to meet other social care needs (i.e., food insecurity, domestic violence, etc.)
• Assisting patients with filling out applications for public and community services such as, Medical Assistance, Housing, SNAP (Supplemental Nutrition Assistance Program) and WIC (Women Infants and Children) Program.
• Providing advocacy, patient education, and support - including accompaniment - in accessing community-based and hospital-based programs.
• Working in partnership with clinic-based care team, including schedulers, practice assistants, nurses, medical interpreters, and…