Community Health Worker Ii

Position if funded through September 30, 2024 with possibility of extension.
The MGH/MGPO manages innovative programming within the Emergency Department (ED) to better serve patients and help navigate their healthcare journey and their health-related social needs.
The goal of the ED Navigator role is to connect patients who present in the ED with internal and external programs and services that will promote better health outcomes. The ED Navigator will work closely with ED staff including physicians, Advanced Practice Providers, social workers, and case managers to identify patients with health-related social needs and/or who need help accessing primary and specialty care, including primary care providers with substance use disorder (SUD) expertise when appropriate and SUD treatment programs when indicated. The ED Navigator assesses and refers patients with health-related social needs (e.g., food insecurity, transportation, housing, violence prevention, etc.), connects patients to appropriate hospital and community programming, and follows up with patients to ensure continuity of care, as appropriate. The ED Navigator will also work collaboratively to help connect these patients to ongoing primary care and the establishment of a regular primary care team.This role will build on current success of the previous ED Navigator program to scale innovative work being done at MGH/PO to increase coordination and continuity of care for underserved and vulnerable populations.
The ED Navigator will engage patients, create a trusting relationship, help navigate patients to community and partner organizations, connect with primary care, make follow-up phone calls and connect to other MGH/PO and Mass General Brigham resources as appropriate.Possible expansion of this program may include closer collaboration with the Substance Use Disorders teams, Psychiatry/Behavioral Health Teams.
While the ED Navigator is not necessarily a clinical role, knowledge of both health systems and community programming are essential components of this job.Having Massachusetts Community Health Worker certification or progress towards getting certification is a plus. Familiarity with an EHR, especially Epic, is preferred.The ED Navigator must be: (1) comfortable with ambiguity and independent work, (2) confident in decision-making, and (3) familiar with concepts of continuous quality improvement.Experience working in an ED or with ED clinical staff is a plus.
Onboarding training in the knowledge and skills necessary to succeed will be provided.Funding for this role is currently secured through September 2024.A weekend shift may be is required and will be determined once hired.
Relevant activities include, but are not limited to the following:
Patient Engagement and Assessment

• Connect with case management and social work teams to complete an initial assessment and referral to internal and external services and programs and develop a follow-up a plan with the patient as appropriate
• Provide advocacy and support in accessing community based and hospital programs
• Coach and motivate patients, utilizing behavioral interviewing techniques, to identify and address barriers to accessing referred services
• Provide culturally competent care to patients from multiple ethnic and cultural backgrounds utilizing interpreter services, when needed.

Systems Navigation

• Manage follow-up with appropriate patients and provide continued connections to care systems and organizations as needed.
• Collaborate, advocate, and communicate with internal departmental resources and programs to link patients to appropriate services and ensure continuity of care

Health Coaching and Care Coordination

• Collaborate with ED staff and Population Health Management program teams to optimize role both within the ED and in collaboration with other MGH staff and with community programs, as appropriate.
• Collaborate with care management team and/or Community Health Worker, if already enrolled, to ensure patient needs have been identified and addressed.

Collaboration and Documentation

• Document each patient encounter using appropriate Epic tools and template. Track benchmarks of progress in care - including short-term goal completion along the way.
• Assess efficacy of systems in order to optimize this work and patient outcomes over time.

Program Assessment and Improvement

• Assist leadership by ensuring data are available to track program progress and success.
• Collaborate with leadership to identify clinical and system workflow barriers to program success.
• Innovate solutions to gaps impeding the program from meeting metrics and achieving its goals.

Other Duties as Assigned
Qualifications
The position requires the ability to be self-directing, outgoing, professional, tactful, and organized and to work as a patient advocate with people from many different cultures and backgrounds.

• BA or BS in Psychology/Social Work/Public Health or related field preferred.High school degree required.Life experience may be able to be substituted for education.
• Two years' experience working in human services required; Experience working in a hospital or health center setting preferred.Experience working in a fast-paced ED or Urgent Care setting preferred.
• Proficiency in developing relationships and networking to improve communication and systems of care.
• Ability to work both independently and as a team member in multicultural settings.
• Solid understanding of social determinants of health.
• Detail-oriented with the ability to multi-task.
• Proficient in Microsoft Office.
• Proficient in an electronic health record, preferably Epic, preferred.
• Strong time management, organizational and planning skills.
• Experience working with Boston and surrounding community organizations and state and local government departments.
• Other language skills a plus.
• Community Health Worker certification a plus.
• Previous training with motivational interviewing skills preferred but not required.

EEO Statement
Massachusetts General Hospital is an Equal Opportunity Employer. By embracing diverse skills, perspectives and ideas, we choose to lead. Applications from protected veterans and individuals with disabilities are strongly encouraged