Hybrid Acute Care Health Outreach Worker - Boston

Why This Role is Important to Us
CCA's Acute Care Health Outreach Worker II (HOW) will provide patient navigation and support for patients with complex medical and social needs and disabilities and will report to the Medical Director of Acute and Urgent Care. The Acute Care HOW II will extend the CCA outpatient model of patient- centered complex care management to the Acute Care setting in the Emergency Department (ED), hospital, and in the patient's homeas a patient navigator, patient advocate, and program support for CCA's ED2Home team. The HOW II will focus on:

• Providing patient assessments in the ED to help determine enrollment in the ED2Home program;
• Navigating patients from the ED to home and conducting the care coordination required for a smooth and successful care transition;
• Setting up patients in their home for ongoing medical management, including setting up technology in the home and teaching patients how and when to use it;
• Conducting social needs assessments of patients, and then mapping discovered needs to appropriate resources in the community;
• Building trust-based relationships with patients and the ED2Home providers;
• Empowering and educating patients to help in self-management of their medical conditions;
• Communicating with ED2Home and primary outpatient care teams to ensure thoughtful care coordination and transitions;
• Developing an expertise in Acute Care patient navigation for complex care patients

The Acute Care HOW II is an essential component of the ED2Home team, helping the team to deliver high-quality, effective, and efficient patient-centered Acute Care CCA members in their homes.
Ideal candidate:

• A CCA HOW who has been in a care partner or RRT role for 2+ years, knows the clinical systems and processes, and has a proven track record for providing Member support, advocacy, and follow-through
• The candidate may be looking for additional responsibilities; e., this role can be considered an advanced HOW position
• Has some hospital and/or Acute Care experience

A successful candidate will be able to:

• Thrive in a fast-paced environment, is self-motivated and organized, has demonstrated ability to connect well and quickly with patients, and values impactful relationships with Members and fellow staff
• Exude passion for the HOW role, and is seeking more responsibility and ability to impact patients' quality of life through direct care
• Serve as a leader for an interdisciplinary team of clinicians involved in patients' care
• Demonstrate empathy during patient encounters
• Set healthy limits and parameters to develop successful working relationships with patients
• The Acute Care HOW will report to the Medical Director of Acute Urgent Care. The HOW will work in close collaboration with the hospital-based CCA team, consisting of a physician, nurse practitioner, and Transitions of Care nurse. The HOW will also communicate regularly and work with each patient's outpatient care team and outpatient HOW to ensure care continuity.

Provide clinical care to members via telehealth technologies (video, chat, etc.) for a clinically appropriate clinical care and care management services.
What You'll Be Doing

• Monday to Friday, 8 a.m. to 5 p.m.
• Documents all clinical work in a timely manner and provides the necessary documentation required for data collection and billing purposes
• Provides detailed sign out and information
• Attends clinical team meetings and other mandatory educational sessions
• Conduct needs assessment while patient is still in ED to evaluate potential for enrollment in ED2Home
• Reviewing SDOH to help determine clinical pathway and assess for program success, including home safety, utilities (internet, electricity), nutrition, etc.
• Guide an interdisciplinary team of clinical personnel (e.g., MD, NP, BH, VNA, PCA, etc.), managing the logistics and ED2Home infrastructure for assigned patients
• Build longitudinal relationships (1-5 days) with patients, making them feel comfortable and supported and ensuring basic needs are being met
• Contribute keen analytical skills, such as the ability to conduct root cause analyses and determine ongoing SDOH needs to guide care partners and the outpatient team
• Participates in orienting and training new employees as required
• Participates in quality assessment and quality improvement within CCA
• Participates in annual clinical team retreats and social/teambuilding events
• Maintains required professional credentialing and appropriate educational standards
• Attends external meetings and activities as a representative of the organization as requested
• Coordinate and complete pharmacy medication pick-up and deliveries for patients, at enrollment and ongoing as-needed
• Coordinate DME needs, including placing authorizations in CMP, and coordinate delivery/pick-up
• Serve as liaison for the patients' family, caregivers, or designated contacts
• Serve as the point-of-contact for the patient: the HOW will be viewed as the Member's go-to "person" during the Acute Care treatment, providing support, care coordination, and navigation
• Set-up, troubleshoot, and maintain technology in home environment
• Conduct social needs assessments, mapping, and navigation
• Oversee and manage the discharge checklist through member profile
• Conduct co-visits with BH clinicians, NPs, paramedics, and other providers as needed, serving as bridge between patient and clinician
• Travel between ED and patients' homes

Working Conditions:

• COVID-19 vaccination is required

What We're Looking For
Qualifications:

• Bachelor's degree required,Master's degree preferred
• 2+ years of progressive, relevant direct member/community collaboration to meet Social Determinants of Health experience in a health care environment
• Proven skills and knowledge base, including knowledge of housing resources and community services, and judgment necessary for independent decision-making
• Proficient in written and oral English communication
• Excellent interpersonal skills, including integrity, good judgment, team work, and diplomacy
• Ability to work quickly to deliver key support and interventions in a timely manner
• Motivated individual who can self-manage
• Willingness and capacity to assume responsibility for tasks
• Ability to juggle many tasks concurrently and prioritize workload in an Acute Care environment with competingdemands and high expectations
• Willing to learn and utilize telehealth technologies (video, chat, etc.), when appropriate, for a variety of clinical care and care management services.
• English required, Spanish, Portuguese, Haitian Creole, Vietnamese preferred