Community Wellness Advocate

POSITION SUMMARY :A Community Wellness Advocate (CWA) is a trusted member of the community who helps high-risk patients maintain stable health and wellness along a continuum, through integrating and connecting hospital, home-based, and community-based services. CWAs are responsible for providing advocacy and case management services; developing an interdisciplinary care plan based on identified patient needs; facilitating access to social service resources and other internal and external resources; monitoring the patient's progress; and problem-solving with patients to both accelerate and enhance access to concrete supports. CWAs provide in-home or community-based support to high-risk patients and collaborate with other members of the patient's care team to help address barriers to the patient's health and wellness.This CWA role will be embedded in the Cardiology clinic at Boston Medical Center and will entail working with patients with congestive heart failure (CHF). Patients with CHF often require comprehensive care due to the complex nature of their condition, which often progresses and worsens over time. Patients with CHF often have symptoms such as shortness of breath and fluid retention, and managing their condition involves closely monitoring medication regimens to optimize cardiac function, and implementing lifestyle modifications like dietary changes and regular exercise to improve overall heart health and quality of life. Additionally, frequent medical assessments and coordination among healthcare providers are essential to address potential complications and ensure a holistic approach to CHF management. The CWA role is essential to facilitating the health and social needs of this patient population.Position: Community Wellness Advocate - Chronic Heart FailureDepartment: Pop-Health Care ManagementSchedule: Full TimeESSENTIAL RESPONSIBILITIES / DUTIES:Initiates face-to-face contact with eligible patients to describe role, explain participation benefits and begin screening process.Schedules and completes initial hospital, clinic, or community-based (homes, shelters, housing agencies, substance use treatment programs, etc.) visit screening, care plan, and follow-up visits and phone calls for enrolled patients within specified timeframes.Teaches key educational messages using a variety of culturally, linguistically and educationally appropriate strategies, in a variety of settings.Clearly documents all activities in the patient's record and care management system.Participates with other staff in activities that include community outreach, presentations to community organizations, development of materials, and phone calls.Works with patients and providers to set goals for patient's care and provides guidance for patient to achieve those goals.Reinforces educational messages regarding disease self-management by linking clients with supportive community services and programs.Presents patients at case review meetings succinctly and logically.Consults with RN/SW Care Manager, primary clinical staff, behavioral health teams and/or PCP regarding complex patient situations, demonstrating an understanding of how to solicit and incorporate provider feedback in order to continuously develop the most optimal plan for care.Demonstrates the ability to function within an inter-disciplinary team (nurse care coordinators, social workers, behavioral health clinicians, physicians, resource specialists, clinical support staff, etc.), connecting the patient with resources as needed.Records and monitors the participants' progress toward goals within specific timeframes.Documents assessments and key patient updates in EMR system; documents relevant day-to-day activities and patient data.Prepares reports and documents as needed or requested.Assists patients with organizing their records, making follow-up appointments, attending follow-up appointments, and filling their prescriptions.Helps patients fill out applications, for example for Medical Assistance, Housing, and SNAP (Supplemental Nutrition Assistance Program).Provides advocacy, patient education and successful warm hand-offs in accessing community-based and hospital-based programs.Assists patient in addressing and overcoming barriers with a range of concrete supports, including but not limited to: healthcare support services, behavioral health, financial assistance, child-care and caregiver support, housing, support with utility bills, food, financial entitlements, clothing, transportation, food pantries, violence prevention, social isolation and any other appropriate community resources.Provides intensive home and community-based outreach, motivational interviewing and goal setting, resource connection and accompaniment to medical appointments as needed to help patients appropriately utilize healthcare.CWAs may visit patients in hospital and ER settings to facilitate transitions of care.Establishes culturally appropriate and trusting relationships with patients and their families.Participates in all training activities as designated by Operations Manager.Attends regularly scheduled supervision and other program assigned meetings.Develops and maintains strong relationships with the community and community resources to ensure patient access.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.JOB REQUIREMENTSEDUCATION:HS Diploma with community experiences or Bachelor's degreeValid Driver's license required and access to reliable transportationEXPERIENCE:Minimum of 2 years prior healthcare, public health, or community-based experience in community setting preferredUnderstanding of our patient population (history of homelessness, experience living with chronic illness, history of substance use disorder, experience in a minority group, etc.) preferred.KNOWLEDGE AND SKILLS:Basic knowledge of healthcare system.Outstanding interpersonal skills of foremost importance to interact with families and patients.Interest in community health and outreach.Exceptional organizational skills; ability to multi-task and work independently and as part of a team.Demonstrated oral and written English communication skills.Fluency in Haitian Creole or Spanish preferable.Understanding of how language, culture and socioeconomic circumstances affect health.Desire to work with diverse, multi-cultural and multi-lingual populations.Proficiency with Microsoft Office applications (i.e. MS Word, Excel, Access, Outlook) and web browsers. Proficiency with data entry and data tracking.Hybrid work setting with community-based, clinic-based work, and some home base.Equal Opportunity Employer/Disabled/Veterans

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