Community Health Worker II - Revere Pediatrics

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The General Hospital Corporation

Mass General Brigham relies on a wide range of professionals, including doctors, nurses, business people, tech experts, researchers, and systems analysts to advance our mission. As a not-for-profit, we support patient care, research, teaching, and community service, striving to provide exceptional care. We believe that high-performing teams drive groundbreaking medical discoveries and invite all applicants to join us and experience what it means to be part of Mass General Brigham.

Responsible for providing advanced health education, outreach, and care coordination services to individuals and families in the community. Areas could include exercise, mental health, medication management, nutrition, health care system navigation, substance use and other health behaviors. They work closely with healthcare providers to ensure that patients receive appropriate care and support services to improve health outcomes.

Does this position require Patient Care? Yes

• Conduct in-depth assessments of patient needs, goals, and barriers to achieving good health outcomes
• Provide advanced health education and coaching to individuals and families to promote healthy behaviors and self-management of chronic conditions
• Collaborate with healthcare providers to develop and implement care plans for patients with complex health needs
• Assist patients in navigating the healthcare system and accessing appropriate services, including health insurance and social services
• Provide ongoing follow-up and support to patients to ensure continuity of care and successful achievement of health goals
• Develop and implement health promotion programs and activities to address community health needs
• Collect data and maintain accurate records of patient interactions and outcomes
• Attend meetings and trainings related to community health promotion and education

MGBfC strives to advance health equity, improve health outcomes, and promote the well-being for all of our patients by addressing health-related social needs, working and overcoming barriers to accessing care.

Community Health Workers (CHWs) are an integral part of achieving these goals. CHWs use their unique skills (knowledge of community resources, motivational interviewing, trauma sensitive care, health coaching, etc.) to help patients coordinate their healthcare, address unmet health-related social needs, and gain confidence in managing their family's health needs. By walking alongside their patients and families, CHWs promote self-efficacy, help patients set and meet their goals, and improve health outcomes.

The MGBfC Community Health Worker is embedded within pediatric primary care, collaborating closely with the multidisciplinary primary care team in order to support families with basic care coordination, assessment of unmet health-related social needs, and navigation to appropriate hospital and community resources to address identified needs. While the Community Health Worker is not a clinical role, it requires a strong knowledge of or the ability to learn basic medical concepts and an understanding of when a referral to a licensed clinician is appropriate.

• Conduct outreach, engagement, and in-depth assessment of patient needs, goals, strengths, and barriers to care
• Assist patients in navigating healthcare, social service, and educational systems and access resources
• Support families with applications and referrals for community resources and benefits
• Examples to include disability supports, community mental and behavioral health resources, autism supports
• Provide ongoing follow-up and support to patients to ensure continuity of care and successful achievement of goals
• Collaborate with healthcare providers to develop and implement care plans for patients with complex health needs
• Facilitate communication between schools and physician
• Supporting requests for school evaluations
• Communicating with schools around observed needs and challenges faced by students
• Maintain knowledge of longer-term network and community care coordination and social service support programs to referrer patients requiring longer term…