Community Health Worker (Bilingual/Russian Speaking Preferred) - NSPG Care Management Program
Company: Partners Healthcare System
Posted on: June 6, 2021
This is a full-time position for someone interested in helping
patients with complex medical and social problems improve their
access and utilization of health care services.
A Community Health Worker (CHW) is a trusted member of the
community who helps patients better access and coordinate their
health care. We believe that CHWs have the skills and experience to
understand what patients are going through and help them get
through difficult times. CHWs are people who come from the
communities they serve. CHWs act as caring neighbors to help
patients address the social and medical problems that lead to poor
health. The goal of a high risk community health worker is to
assist the high risk patients with the tasks of getting medical
care, working on health goals (such as arranging care, filling
medication prescriptions, planning healthy meals, or finding time
to exercise), and to help them deal with the "real-life" issues
that keep them from staying healthy. Although a CHW is not in a
clinical role, having the capacity to learn basic clinical concepts
in order to identify when a referral to a licensed clinician is
appropriate is an important skill.
The CHW will work with high risk patients receiving care at
NSPG/NSHC. This high-risk patient population presents a unique set
of challenges, including higher rates of mental illness and
substance abuse. These patients are also often harder to contact
and engage, as well as having weaker ties to their primary care
practice. Many of these patients visit their local emergency
department instead of their primary care doctor and receive
fragmented care. Our project aims to integrate CHWs into the
primary care team, serving as a bridge between the primary care
team and patients in the community that are at high risk but are
disconnected with primary care. By doing so we hope to re-engage
patients with their primary care team and improve their patient
experience and health outcomes. As a CHW on this project, you will
develop trusting working relationships with the patients you work
with and be supported by a primary care team that includes primary
care physicians, care coordinators, and social workers.
- Provide community health work services for patients identified
as high risk due to medical and/or psychosocial challenges.
- Attend initial and continuing education training programs
including self-directed reading and in-person and online
- Work with patient and provider to set goals for patient's
- Meet patients in their homes and community to perform
structured assessments that include goal setting.
- Meet patients in the emergency department, primary care clinic
or hospital to reinforce and advance patient goals.
- Make weekly follow-up calls and regular home visits to patients
- Motivate patients to meet their health goals.
- Provide culturally sensitive services to patients from
- Coordinate with the iCMP Resource Specialists to access
resources for identified problems including homelessness, substance
abuse and food insecurity after assessment by a licensed social
worker clinician. iCMP is Partners HealthCare's "Integrated Care
Management Program," a longitudinal, primary care-embedded care
management program for high risk patients.
- Assist patients with organizing their medical care needs such
as making follow-up appointments, and filling their
- Help patients fill out applications for community services such
as Medical Assistance and SNAP (Supplemental Nutrition Assistance
- Provide advocacy, patient education and support in accessing
community-based and hospital-based programs.
- Refer to internal or external care management services when
other issues are identified (i.e. food insecurity, domestic
- Develop and maintain strong working relationships with the iCMP
nurse care coordinator, iCMP behavioral resource specialist,
primary care physician and community behavioral health team.
- Document each patient encounter in detail.
- Prepare reports and documents as needed or requested.
- Attend a weekly group meeting with program supervisors.
- Other duties as reasonably assigned.
Preferred: Bachelor's Degree
Preferred: Bilingual language skills
Keywords: Partners Healthcare System, Peabody , Community Health Worker (Bilingual/Russian Speaking Preferred) - NSPG Care Management Program, Other , Peabody, Massachusetts
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