Care Coordinator​/CHW

Based in the heart of downtown Lowell, Massachusetts Lowell Community Health Center is currently seeking a Full-Time Nurse Community Health Worker/Care Coordinator.

With over 400 employees, the Health Center has expanded and relocated to a new state‑of‑the‑art facility as of December 2012. The Health Center is a diverse, community‑based health care organization. Lowell Community Health Center programs have been recognized as national models. The Health Center was also named one of the top five health centers in the nation for excellence in cultural competency.

The Health Center's employees speak 28 different languages and over 80 staff are trained in medical interpreting.

• Patients trust Lowell Community Health Center. Every year, we touch the lives of nearly 50,000 people – or almost half the population of the City of Lowell.
• More than 90% of Lowell CHC patients are low income, and 46% are best served in a language other than English.
• Since opening our new comprehensive facility in a renovated mill on Jackson Street in 2012, more than 9,000 additional patients have turned to Lowell CHC for a full range of primary care, including OB‑GYN and behavioral health services for adults and children, with over 176,000 visits in 2014.
• We also have a Pharmacy serving health center patients and others in the community.

SUMMARY:

Full Time (40 hours per week). Some evenings and weekends required, inclusive in the 40‑hour work week. The Care Coordinator/Community Health Worker (CHW) will be an integral member of an interdisciplinary Behavioral Health and Primary Care Integration team in Pediatrics and Family Medicine Departments. The CHW will work closely with patients, care managers, other care management team members, health care providers, behavioral health and social services providers, and community partners to effectively manage the care of designated patients.

REQUIREMENTS:

• Care Management
• Assist Children’s Mental Health Initiative (CMHI) team in monitoring and evaluating patients’ needs, including for prevention, wellness, medical, specialist, and behavioral health treatment; care transitions; and social and community service needs. Support the development and execution of patients’ care plans, including assisting patients in understanding care plans and instructions and tailoring communications to appropriate health literacy levels.
• Conduct initial and periodic needs assessments, including assessing barriers and assets (e.g., transportation, community barriers, social supports); patient and family or caregiver preferences; and language, literacy, and cultural preferences.
• Promote patient treatment adherence through assessing patient readiness to make changes; assisting patients and families in making changes to daily routines; identifying barriers; and assisting patients with developing strategies to address barriers.
• Provide informal counseling, behavioral change support, and assistance with goal setting and action planning.
• Provide support for chronic disease self‑management to patients and their families.
• Provide information on patients to care managers, other care team members, and providers.
• Manually and/or electronically document activities and patient information and interventions in patient‑tracking systems, care management software programs, and other program systems.
• Use health information technology/systems to link to services and resources and communicate among team members, providers, and patients and their families/caregivers.
• Collect and report on data for program evaluation.
• Systems Navigation
• Coordinate access to the basic determinants of health (e.g., food, clothing, shelter, income, utilities).
• Assist patients with navigating health care and social service systems,…