The Community Wellness Advocate (CWA) is a key member of the Practice of the Future innovation team who helps promote and maintain stable health and wellness for families, through integrating and connecting hospital, home-based, and community-based services. CWAs are responsible for providing advocacy and case management services; developing and tracking an interdisciplinary care plan based on identified patient needs; partnering with families to establish and enact health goals; facilitating access to and coordination among social service resources and other internal and external resources; monitoring the families' progress; and problem-solving with patients to both accelerate and enhance access to concrete supports.
CWAs provide clinic-based, in-home or community-based one-on-one, family, and/or interdisciplinary group support and collaborate with all members of the care team to conduct needs assessments to identify and respond to barriers to the families' health and wellness. As a member of an innovation team tasked with testing new and novel care delivery approaches, the specific activities of the CWA may evolve over times as the Practice of the Future model evolves.
ESSENTIAL RESPONSIBILITIES / DUTIES:
The following are key activities expected for this role:
- Functions a key member of an inter-disciplinary team (nurse, social workers, behavioral health clinicians, physicians, resource specialists, clinical support staff, etc.)
- Provides parent coaching and support, including outreach to and engagement with families to define individual goals, promote healthy development and access to care and services
- 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
- Assists families in addressing and overcoming barriers with a range of concrete supports, including but not limited to: healthcare support services, behavioral health, financial mobility coaching, school-based interventions, early-intervention, 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
- Teaches families key educational and developmental 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. Records and monitors the participants' progress toward goals within specific timeframes. Documents assessments and key patient updates in Epic system; documents relevant day-to-day activities and patient data.
- Communicates plans and updates with members of the care team
- Works in partnership with the SW to comprehensively assess families' needs and strengths
- Develops and maintains strong relationships with the community and community resources to ensure patient access
- Engages in ongoing training and learning
Must adhere to all of BMC's RESPECT behavioral standards.
(The above statements in this job description are intended to depict the general nature and level of work assigned to the employee(s) in this job. The above is not intended to represent an exhaustive list of accountable duties and responsibilities required).
HS Diploma preferred with knowledge of MA community services landscape (specific knowledge of services in Dorchester and Roxbury preferred) or bachelor's degree
CERTIFICATES, LICENSES, REGISTRATIONS REQUIRED:
MA Driver's License required
2-5 years of prior healthcare, public health, mental health, or community-based programmatic experience preferred
Bilingual, preferably in English and either Spanish or Haitian Creole
KNOWLEDGE AND SKILLS:
- Basic knowledge of healthcare system and social service landscape
- Outstanding interpersonal and communication skills
- Understanding of how language, culture and socioeconomic circumstances affect health
Req ID: 14895Apply