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Community Health Worker - Brookline Pediatrics

Company: Partners Community Physicians Organization(PCPO)
Location: Brookline
Posted on: May 3, 2021

Job Description:

General OverviewA Pediatric Community Health Worker (PCHW) is a trusted member of the community who helps patients' and family's better access and coordinate their health care. PCHWs have the skills and experience to understand what patients and Families are going through and help them get through difficult times. PCHWs are people who come from the communities they serve. PCHWs act as caring neighbors to help patients and families address the social and medical problems that lead to poor health.The goal of the Pediatric Community Health Worker is to work with patients and families identified by their Pediatrician and team due to medical, psychosocial, recourse and other needs. The PCHW will also work on creating a trusting relationship with patients and families and support them when addressing social determinant of health needs such as food, housing, transportation, etc., and connecting them to resources. The PCHW will work to engage families on adhering to key components of their health care. Some of these areas may include navigating families to important appointments, making follow up home visits (or "porch" visits during the COVID pandemic,) meeting with patients and families in the clinical setting and closely communicating with the provider team based on goals set out through the referral process. The pediatric community health worker will engage patients and their families in setting their own short-term goals and will track the benchmarks along the way toward the achievement of these goals. The PCHW will aid families in the coordination and completion of appointments inside and outside of the primary care practice. In addition, the community health worker will work with families to help decrease barriers to timely follow-up care. While the community health worker is not a clinical position, it requires knowledge (ability to learn) of basic clinical concepts and an understanding of when a referral to a licensed clinician is appropriate.Duties and ResponsibilitiesProvide community health work services for patients and families identified due to medical, psychosocial or other challenges, including short term intensive management and in person support as needed to enable patients to access appropriate services, benefits, and programs.Support community resource finding related to SDOH needs, including food, housing, transportation, schooling, IEPs and other areas as needed.Attend initial and continuing education training programs including self-directed reading and in-person and online learning.Work with patients and providers to set goals for patient's care and motivate families to meet their health goals.Work with the family to identify and help to address barriers to care.Provide culturally sensitive services to families from different cultures. Help the family to put systems in place in their own environment to assist with the management of their care. Help to address any logistical barriers, scheduling complications, childcare needs, etc., that would prevent a patient from showing up at their appointment.Assist families in organizing their records, making follow up appointments and filling their prescriptions.Help families to develop their own plans for getting to various appointments for screening and diagnostic tests, and treatment services.Meet families in the community or conduct "porch" visits when and where appropriate to follow up on key aspects of the patient's care and to assess the in-home barriers to compliance and engage families in addressing their barriers.Maintain regular communication with the patient's providers through clinical messages in the electronic health record, emails, phone calls and case review meetings.Document each patient encounter in detail. Track benchmarks of progress in care - including short term goal completion along the way. Work with pediatricians to reinforce health education messages - the importance of follow-up care, medication adherence, routines of self care, etc.Refer to care management services when other issues are identified (i.e. food insecurity, domestic violence, etc.)Help patients fill out applications for community services such as Medical Assistance and SNAP (Supplemental Nutrition Assistance Program).Provide advocacy, patient education, and support in accessing community-based and hospital-based programs. Enter notes of intervention into the appropriate electronic health record.Develop and maintain a strong working relationship with the schedulers of screening appointments.Work with medical interpreters to reach patients of other languages.Produce regular reports on program activities compiling data from data bases and writing up case examples. Qualifications High school degree required. Associates or Bachelor's Degree preferred.Minimum two years of working experience. Demonstrated commitment to impacting the care of high-risk patients.Experience working as a patient navigator/community health worker preferred.Experience in a clinical setting, especially as a Medical Assistant, preferred.Ability to work both independently and as a team member in multicultural settings.Ability to work in a highly matrixed environment, with many competing priorities.Fluency in Spanish and/or Portuguese preferredDetail-oriented with the ability to multi-task.Proficient in all Microsoft Applications, including MS Office and Excel. Proficiency in EPIC preferred.Strong time management, organizational and planning skills.EEO Statement Equal Opportunity Employer

Keywords: Partners Community Physicians Organization(PCPO), Brookline , Community Health Worker - Brookline Pediatrics, Other , Brookline, Massachusetts

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