Community Wellness Advocate

The Enhanced Care Program for Seniors (ECAP) is a collaborative, interdisciplinary wrap around clinical program which provides medical and social support to complex, and vulnerable elderly patients followed within the Boston Medical Center Health System. Through home visits in the community the ECAP supports patients in managing their complex medical and social issues, empowering them to address social determinants of health which present barriers to maximizing their health status and engaging in their healthcare.

The interdisciplinary team, composed of a geriatrician, nurse practitioners, community health workers, pharmacy liaison and administrative support, work collaboratively to identify and address patients’ needs and care gaps to empower and activate patients and families to engage in their healthcare.

Community Wellness Advocate

Pop Health - Value Based Core

Full Time

(CCHW) Community health worker

• Initiates face to face contact with eligible patients to describe role, explain participation benefits and begin screening process.
• Schedules and completes initial hospital, clinic, or community-based (homes, shelters, housing agencies, substance use treatment programs, etc.) visit screening, care plan, and follow up visits and phone calls for enrolled patients within specified time frames.
• Teaches key educational messages using a variety of culturally, linguistically and educationally appropriate strategies, in a variety of settings.
• Clearly documents all activities in the patient’s record and care management system.
• Participates with other staff in activities that include community outreach, presentations to community organizations, development of materials, and phone calls.
• Works with patients and providers to set goals for patient’s care and provides guidance for patient to achieve those goals.
• Reinforces educational messages regarding disease self-management by linking clients with supportive community services and programs.
• Presents patients at case review meetings succinctly and logically.
• Consults with Patient Care Manager, primary clinical staff, behavioral health teams and / or PCP regarding complex patient situations, demonstrating an understanding of how to solicit and incorporate provider feedback in order to continuously develop the most optimal plan for care.
• Demonstrates the ability to function within an inter-disciplinary team (nurse care coordinators, social workers, behavioral health clinicians, physicians, resource specialists, clinical support staff, etc.), connecting the patient with resources as needed.
• Records and monitors the participants’ progress toward goals within specific time frames.
• Documents assessments and key patient updates in Epic system; documents relevant day-to-day activities and patient data.
• Prepares reports and documents as needed or requested.
• Assists patients with organizing their records, making follow-up appointments, attending follow-up appointments, and filling their prescriptions.
• Helps patients fill out applications, for example for Medical Assistance, Housing, and SNAP (Supplemental Nutrition Assistance Program).
• Provides advocacy, patient education and successful warm hand offs in accessing community-based and hospital-based programs.
• Assists patient in addressing and overcoming barriers with a range of concrete supports, including but not limited to: healthcare support services, behavioral health, financial assistance, child-care and caregiver support, housing, support with utility bills, food, financial entitlements, clothing, transportation, food pantries, violence prevention, social isolation and any other appropriate community resources.
• Coordinates…