Care Coordinator/CHW

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, including arranging for transportation and scheduling and accompanying patients to appointments.
• Identify available community-based resources and actively manage appropriate referrals, access, engagement, follow-up, and coordination of services.
• Coordinate patients’ access to individual and family supports and resources, including resources related to housing; prevention of mental illness and substance use disorders; smoking cessation; chronic conditions; self-help/recovery resources; and other services based on individual needs and preferences.

• Community Outreach and Education

• Conduct patient outreach and engagement activities to designated CMHI patients and families, including face-to-face (at Lowell Community Health Center and/or at the patients’ homes), mail, electronic, and telephone contact.
• Conduct outreach and engagement activities that support patient continuity of care, including re-engaging patients in care if they miss appointments and/or do not follow up on treatment.
• Participation and presence at community events (e.g., cultural festivals, Mobile Markets, Adult Education Center work, etc.).

SUPERVISORY RESPONSIBILITIES: None

QUALIFICATIONS/EDUCATION and/or EXPERIENCE:

• TWO YEARS EXPERIENCE IN COMMUNITY OUTREACH OR OTHER HUMAN SERVICES; related education may be substituted for one year experience.
• High School diploma or equivalent required.
• Bachelor’s in related field preferred.
• Successful completion of a Community Health Worker, Outreach, or Patient Navigation Certificate Program preferred.

· Strong knowledge of the surrounding community and existing resources.

• Experience working in an interdisciplinary, multi-cultural setting (e.g,. community-based or health care setting).

· Understanding of multi-cultural beliefs, practices, and culture, as well as sensitivity to varying socioeconomic backgrounds.

· Works well in a fast-paced environment where daily schedules and routines may change rapidly due to high patient volume, unexpected needs, or no-shows.

· Knowledge of some medical terminology preferred.

· Experience with children and families preferred.

• Basic computer skills.

• Ability to initiate and maintain positive working relationships with staff and other organizations.

• Ability and willingness to provide emotional support, encouragement and motivation to patients

• Must be able to work independently and demonstrate attention to detail, accuracy. and quality awareness.

• Must have reliable transportation and a valid Massachusetts license.

LANGUAGE SKILLS Bilingual in English and Spanish, Portuguese or Khmer preferred, with ability to read, write and speak in public forums.

PHYSICAL DEMANDS The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. The employee may lift and/or move up to 25lbs while at work.

WORK ENVIRONMENT The work environment characteristics here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this job, the employee may be exposed to weather conditions such as heat, rain, wind and snow. The noise level in the work environment is usually moderate.

All your information will be kept confidential according to EEO guidelines.