Community Wellness Advocate

POSITION SUMMARY:

Boston Medical Center Health System (BMCHS) is a leading academic medical center with a deep commitment to health equity and a proud history of serving all who come to us for care. BMC provides high-quality healthcare and support, extending beyond our physical campus into our vibrant and diverse communities. As a core member of the Boston Medical Center Health System, BMC is advancing medicine and training the next generation of healthcare providers and researchers.

In 2021 BMC launched the "Health Equity Accelerator" with the purpose of 'transforming healthcare to deliver health justice and well-being'. The Accelerator, in partnership with Population Health, is developing an innovative multi-disciplinary approach that combines clinical operations, community engagement, health-related social needs programs, and research assets to address racial health inequities.

The Community Wellness Advocate (CWA) is a trusted member of the community who helps promote and maintain stable health and wellness for patients and families through connections to the program and community-based services. The CWA is responsible for providing advocacy and case management services for patients throughout the program. This role will work as part of the program's multidisciplinary care team to address any barriers or challenges that may prevent participation in care. The CWA will partner with the Community Health Equity Manager in identifying and developing programming to offer patients throughout the program around economic mobility and nutrition security.

The CWA will play a critical part in population health management and patient navigation, contributing to the overall effectiveness of the program. This role requires strong communication skills, emotional intelligence, and a commitment to advancing health equity.

Position: Community Wellness Advocate

Department: MGB Diabetes Initiative

Schedule: Full Time

ESSENTIAL RESPONSIBILITIES / DUTIES:

Care coordination and case management

• Functions as a key member of the interdisciplinary program team (nurse practitioner, behavioral health clinician, patient navigators, etc.)

• Works closely with the Patient Navigators and other care team members to identify patients requiring support

• Schedules and completes community-based visits (e.g., homes, community organizations, community spaces)

• Teaches key educational messages using a variety of culturally, linguistically and educationally appropriate strategies in a variety of settings

• Works with patients and program care team to set goals for the patient's care and provide guidance to the patient to achieve those goals

• Periodically uses standardized questionnaires (e.g. THRIVE and PAID-5) to identify social determinants of health (SDOH)

Documentation and database management

• Develops and documents barriers to care and plans for resource connections

• Documents assessments and key patient updates in EPIC system

• Clearly documents all activities in the patient's record and care management system

• Presents patient cases during team huddles succinctly and logically

• Attends regularly scheduled supervision and other program assigned meetings

• Maintains database of community-based resources in partnership with other program staff

Community programming and support

• Attends group programming to build relationships with program patients and identify areas for support

• Participates with other staff in activities that include community outreach, presentations to community organizations, development of materials, and phone calls

• Partner with the Community Health Equity Manager to identify and develop community-based programming around economic mobility and nutrition security

• Reinforces educational messages regarding condition self-management by linking patients with support community-based services and programs

• Provided advocacy, patient education, and successful warm hand-offs in accessing community-based programs and coordinates long-term support beyond the program

• Develops and maintains strong relationships with the community and community resources to ensure patient access

• Assists with facilitation of community and patient listening sessions

NOTE: The CWA will not provide hands on care or other services noted as home health services, including but not limited to performance assessments, provision of care, treatment, or counseling; and/or monitoring of patient's health status.

Qualifications

Education:

• HS Diploma with community experience required

• BSW, Associate's degree in health care or a related area or equivalent relevant work experience (preferred)

Experience Required:

• Minimum of 1 year prior in healthcare, public health, or community-based experience preferably working with adults

Experience Preferred/Desirable:

• Prior work with Medicaid population preferred

• Experience with care coordination/care management

• Experience in healthcare database/medical management system

• Prior customer service experience

• Training in motivational interviewing techniques

• Knowledge and experience in evidence-based prevention programs

• Bilingual

• Successful completion of Community Health Worker formal training/certification program or equivalent

Competencies, Skills, and Attributes:

• Multilingual skills in languages appropriate to the patient populations served by the medical center preferred (Spanish or Haitian Creole).
• Familiar with Mattapan community and surrounding zip codes.
• Strong interest in social determinants of health and advancing racial health equity.
• Outstanding interpersonal skills to interact with families and patients.
• Basic knowledge of the healthcare system.
• Interest in community health and outreach.
• Exceptional organizational skills: ability to multi-task and work independently as well as part of a team
• Understanding of how language, culture, and socioeconomic circumstances affect health.
• Knowledge of software applications such as Microsoft Office, and electronic medical record systems
• Ability to build and manage relationships in a highly complex and changing environment
• Demonstrated ability to handle stressful situations in a calm and professional manner
• Effective verbal and written communication skills appropriate to the patient populations served.
• Physical ability to meet the core job responsibilities in accordance with practice setting demands.

Equal Opportunity Employer/Disabled/Veterans