Community Health Worker Bridges to Moms Programs

GENERAL SUMMARY/ OVERVIEW STATEMENT:

At Mass General Brigham we believe in equal access to quality care, employment and advancement opportunities encompassing the full spectrum of human diversity: race, gender identity, sexual orientation, ability, religion, ethnicity, national origin and all the other forms of human presence and expression that make us better able to provide innovative and cutting-edge healthcare and research.

BWH seeks a full-time CHW to work in the Bridges to Moms Program, helping to address gaps in social determinants of health for Obstetrics patients who are homeless or facing imminent homelessness, and providing long-term follow-up and care coordination through the baby's first year.

The Community Health Worker (CHW) is a vital role within Brigham and Women's. A CHW is a trusted member of the community who supports patients to better access and coordinate their health care. In partnership with patients, CHWs have the skills and experience to navigate resources and support patients get through difficult experiences. CHWs come from the communities they serve and act as an extension of caring neighbors to help patients meet their social and medical needs which can lead to better health outcomes. The CHW dedicates her/his time to establishing a trusting relationship with patients to address social determinant of health (SDOH) needs such as food, housing, transportation, and connecting them to resources. In addition, the CHW works with patients to help decrease barriers to connecting to primary care in order to ensure long-term access to care. While the Community Health Worker is not a clinical position, it requires knowledge of (ability to learn) basic clinical concepts and an understanding of how primary and social care teams work together to achieve best possible health outcomes.

Qualifications

PRINCIPAL DUTIES AND RESPONSIBILITIES:

• Provide community health services for pregnant and post-partum patients in the Bridges to Moms Program, including short term intensive case management and in person support as needed to advocate for appropriate services, benefits, and programs.
• Support closing gaps in community resources related to Social Determinants of Health (SDOH) needs, including assistance with housing and/or emergency shelter applications, food, transportation, utilities, medication costs, childcare, and health education needs.
• Work in partnership with the patient to identify and address barriers to care.
• Collaborate with patients and providers to set goals for patient's care and motivate patients to meet their health goals. Document and track progress accordingly.
• Provide culturally sensitive and responsive services to patients from diverse cultures and communities.
• Support the patient to further develop systems within their environment to assist with the overall management of their care.
• Co-develop strategies to reduce logistic barriers to care, such as, scheduling conflicts, childcare needs, and transportation that would prevent a patient from attending appointments, tests, treatment, etc.
• Assist patients in organizing their records, making follow up appointments and filling their prescriptions as needed.
• Accompany patients to appointments when needed to provide support and advocacy.
• Identify patient strengths to manage their own care.
• Meet patients in the community or conduct "porch" visits when and where appropriate to follow up on key aspects of the patient's care, assess barriers within the home and identify potential solutions.
• Maintain regular communication with the patient's provider and provider's care teams through health record database, emails, phone calls and case review meetings.
• Follow documentation guidelines and protocol within health record database and other areas as assigned and determined by BTM Director and Program Manager.
• Work with BTM Director to refer to internal or external care management services when additional capacity is required to meet other social care needs (i.e., food insecurity, domestic violence, etc.)
• Assist patients with filling out applications for public and community services such as, Medical Assistance, Housing, SNAP (Supplemental Nutrition Assistance Program) and WIC (Women Infants and Children) Program.
• Provide advocacy, patient education, and support - including accompaniment - in accessing community-based and hospital-based programs.
• Work in partnership with clinic-based care team, including schedulers, practice assistants, nurses, medical interpreters, and others.
• Contribute to mid-year and end of the year reports describing program and case examples.
• Attend initial and continuing education training programs including self-directed reading and in-person and online learning.

QUALIFICATIONS:

The community health worker position requires the ability to be self-directing, motivated, outgoing, professional, goal-oriented, organized and to work as a patient advocate with people from diverse cultures and backgrounds.

• Minimum two years of relevant work experience in the community or Associates Degree
• High school degree required.

SKILLS/ ABILITIES/ COMPETENCIES REQUIRED:

• Knowledge of community-based program services, housing and shelter applications, public benefits, and other resources.
• Excellent communication skills.
• Strength in authentically connecting with people from all walks of life with empathy and humility.
• Strong attention to detail and prioritization.
• Familiarity and willingness to learn service approach models (e.g., trauma informed, cultural humility, strength-based, and others).
• Strong time management and planning skills.
• Ability to make connections across internal and external teams of care.
• Excellent organizational skills given coordination of multidisciplinary team, various logistical components, data acquisition.
• Ability to work well within a team and independently.
• Computer skills: working knowledge, familiarity with computer, software including use of email, excel.
• Willingness to learn and further develop skills reflective of best practices and trends in the field.
• Fluency in English and also Spanish or Haitian Creole required

EEO Statement

BWH is an Affirmative Action Employer. By embracing diverse skills, perspectives and ideas, we choose to lead. All qualified applicants will receive consideration for employment without regard to race, color, religious creed, national origin, sex, age, gender identity, disability, sexual orientation, military service, genetic information, and/or other status protected under law. We will ensure that all individuals with a disability are provided a reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment.