Community Health Worker; Hybrid​/Mobile – Metro West​/Massachusetts

Commonwealth Care Alliance's (CCA) Care Delivery programing is responsible for providing care delivery and care management to a specific panel of high risk and complex people. Founded in 1977, the practice known today as CCA Primary Care is a Massachusetts based provider nationally recognized as a leader in the care of individuals facing complex challenges. Today, the impact of our care delivery program is wider than it has ever been – serving over a thousand of individuals across the state.

Join a team committed to serving complex individuals with the best possible care in a unique, comprehensive and quality focused model. We are a specialized interdisciplinary team engaged in collaborative care with a wide range of resources. Our goal is to improve the lives of the people we serve and help keep them at home, by providing best-in-class disability competent care.

Within Care Delivery, the Community Health Worker (CHW) functions as an integral member of an interdisciplinary team for care delivery and care coordination for the most complex medical and behavioral health patients. The CHW participates in aiding the patients around all social determinants of health (SDOH) needs in the context of the patient centric individualized plan of care. The CHW uses evidence-based resources, knowledge of community-based care and support, trauma/recovery skills, and health coaching/education to influence the outcomes of assigned patients by impacting acute care utilization, ensuring optimal treatment and closing gaps in care through connecting patients with community supports.

The CHW will help the patient 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 patients' engagement with primary care, behavioral health, and substance use services. The CHW will play an integral role supporting patients with frequent utilization of Emergency Departments and acute admissions with the goal of identifying SDOH factors that may be contributing, and partnering with the patient to identify more efficacious and appropriate supports that empower the patient and meet his/her needs.

This position reports to a Care Delivery Clinical Manager

• The primary function of the Care Delivery CHW role is delivering care to CCA’s most complex patients, providing care management and care coordination support, and collaborating with external providers with the goal of delivering comprehensive care.
• Essential Duties Include – best in class patient care; clear, concise, and effective communication and documentation; and interdisciplinary collaboration with a variety of stakeholders internally and externally.
• Patient Care:
• Engage in regular assessments pertaining to patients Social Determinants of Health
• Conduct visits/outreaches to patients telephonically, virtually, or in-person at regularly scheduled intervals.
• Conduct urgent follow-ups to address patients’ significant social needs (medical or behavioral health)
• Conducts coaching and education towards the promotion of wellness, and the prevention and reduction of health risks.
• Supports the health education needs of the patient in collaboration with the interprofessional care team and PCP
• Assess health risks, identify gaps pertaining to SDOH issues that create barriers to care and/or contribute to unmet needs
• Conducts closed loop communication with patients’ external providers including the PCP and CCA’s interprofessional team to identify areas of opportunity, define resources, and coordinate implementation of care plan.
• Collaborate with patients on SDOH goals in care plan and provide support and education for key care management or…