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.

A Community Wellness Advocate (CWA) is a trusted member of the community who helps high risk patients maintain stable health and wellness along a continuum, through integrating and connecting hospital, home-based, and community-based services. CWAs are responsible for providing advocacy and case management services; developing an interdisciplinary care plan based on identified patient needs; facilitating access to social service resources and other internal and external resources;

monitoring the patient’s progress; and problem-solving with patients to both accelerate and enhance access to concrete supports.

CWAs provide in-home or community-based one-on-one, family, and/or interdisciplinary group support to high risk care patients and collaborates with the Patient Care Manager, PCP, and other members of the care team to conduct needs assessments to identify and respond to barriers to the patient’s health and wellness.

Position :
Community Wellness Advocate

Department: Pop Health - Value Based Core

Schedule :
Full Time

Required Certificatio
n: (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;…