Job Description

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 program and community-based services. The CWA will serve as the patient’s guide throughout the program and is responsible for supporting patients in the management of their conditions (hypertension, diabetes, and obesity). This role will perform direct outreach to patients, families, and/or caregivers to provide culturally appropriate follow-up. CWAs will also partner with patients to identify and address any barriers or challenges that may prevent access to care and connect them with the appropriate care team members. A critical role of the CWA is to act as the liaison between the patient and the program care team. As the liaison, the Navigator will help to distill medical information delivered from care team members down into digestible “plain language” to assist the patient in managing their condition. To manage this effectively, the CWA will need to build relationships with care team members to support patients’ health goals and priorities. 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 our 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

• Manage a panel of patients engaged in various stages of the program
• Assesses patients social, financial and family resources and connects patients to available program and community resources in partnership with the other program team members
• Uses standardized questionnaires including (e.g., THRIVE and PAID-5) to identify social determinants of health (SDOH) and diabetes, hypertension, and obesity related distress
• 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
• Work with patients and program care team to set goals for the patient’s care and provide guidance to the patient to achieve those goals
• Presents patient cases during team huddles succinctly and logically
• Facilitates the flow of information between patient, provider and other program team members and distills medical information down into “digestible plain language”
• Attends trainings and professional development opportunities to maintain knowledge of chronic disease management and available resources

Patient navigation

• Serves as a central contact for patients navigating diabetes, hypertension, and obesity care in the program as part of the multidisciplinary care team
• Schedules appointments for patients, ensuring that they receive timely reminders and follow-up care
• Leverages Motivational Interviewing technics or similar tools to engage patients and provides emotional support to patients and their families throughout the program
• Verifies and updates patient insurance information when scheduling any visits
• Proactively contacts patients to resolve and follow-up on potential barriers for appointment completion
• Provides general clerical support including filing, making appointments, photocopying, faxing, preparing and sending mail, making reminder phone calls, and maintaining contacts database
• Facilitates distribution of patient’s remote monitoring devices
• Ensures patient’s remote monitoring data is flowing into the EMR and troubleshooting any issues that arise
• Provides and receives constructive feedback from team members and patients

Documentation and database management

• Documents patient communication in the Electronic Medical Record (EMR) using encounter notes, inbasket messages and MyChart
• Develops and documents barriers to care and plans for resource connections
• Documents assessments and key patient updates in EPIC system
• Clearly document 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
• Provides 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
• Contributes to the development of new ideas that impact the program

General Duties and Standards

• Adapts to changes with departmental needs including but not limited to offering assistance to other team members, floating, adjusting assignments, etc.
• Conforms to hospital standards of performance and conduct, including those pertaining to patient rights and HIPAA and privacy rules, so that the best possible customer service and patient care may be provided
• Utilizes hospital’s behavioral standards as the basis for decision making and to support the department and the hospital’s mission and goals
• Follows established hospital infection control and safety procedures
• Performs other duties as assigned to support overall program priorities

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 2 years prior in healthcare, public health, or community-based experience preferably working with adults

Knowledge, Skills, Abilities:

• 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

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