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Community Health Worker MassHealth ACO

Job ID 148187 Date posted 06/02/2018

Position Summary:
LMH-ACO is responsible for improving coordination of patient care, reducing unnecessary hospitalizations and readmissions, emergency department visits and revists, and reducing total cost of care over time. LMH-ACO will provide services in collaboration with contracted Managed Care Organizations (MCOs) as well as Community Partners (CPs) for Behavioral Health (BH) and Long Term Services and Supports (LTSS), as appropriate.

Working under the direction of a Licensed Social Worker, the LMH-ACO Community Health Worker (CHW) will work directly with members, families, and caregivers to perform outreach and engagement and to assist with care coordination, care management, and care transition functions and activities for assigned LMH-ACO members. The CHW will work with at-risk members and families in all settings including their homes, to assess the member?s health care needs, social service needs, and social obstacles to health. The CHW will connect members to appropriate, available providers and community resources, with goals of improving the member?s quality of life and increasing their access to health care - related programs and services at the appropriate time and in the most appropriate settings.

Essential Duties & Responsibilities (including but not limited to):
As an active member of the LMH-ACO Care Management team, this position:
- Establishes and maintains a supportive relationship with assigned members
- Engages members who meet high/moderate risk complexity eligibility via multiple modalities
(face to face; telephone; email; text) at a frequency determined by member need and as agreed upon by the member, working under the direction of the Social Worker (and RN Care Manager as appropriate)
- Conducts outreach and engagement activities and provides information about the benefits, design and purpose of the LMH-ACO Care Management Program
- Documents each outreach attempt in the LMH-ACO care management electronic record, with follow-up schedule clearly indicated
- Documents ?unable to reach? members and members who decline Care Management services; collaborates with member?s LMH-ACO Social Worker or RN Care Manager to identify other approaches and resources for member outreach and engagement
- Provides active, non-judgmental listening and, where applicable, conducts motivational interviewing
- Facilitates scheduling of Comprehensive Assessments, face-to-face whenever possible and appropriate
- Identifies member social needs and cultural preferences, including arranging for interpreter services as needed
- Contributes to member Comprehensive Assessments by gathering and documenting information from the member, family, health care and social service providers and other stakeholders, as assigned
- Ensures that the member understands their rights and how to file any complaints or grievances
- Provides care management team service support as directed
- Facilitates communication and coordination between the member or designated representative and member?s PCP and other healthcare providers, including BH and LTSS CPs
- Facilitates linkages to member?s peer networks/natural supports, when available and appropriate
- Facilitates and coordinates member referrals to community social service providers as requested by member?s Social Worker, RN Care Manager, or PCP and as agreed to by the member
- Assists member to navigate the available network of community-based services
- Follows-up on member referrals to determine outcomes
- Assists members to access further treatment, self-help groups, housing and other social services related to medical /behavioral health and other care needs
- Provides educational materials on mental health and substance use disorders and treatment options to the member and his/her family or natural supports, as directed by the member?s PCP, Social Worker, or RN Care Manager
- Addresses housing needs (makes an effort to explore and partner with local housing authority for temporary and permanent housing)
- Offers appropriate health and wellness coaching programs and activities; offers health and wellness education materials in preferred language and formats, when needed
- Attends Care Management Team meetings and case reviews as scheduled or as requested by Social Worker, RN Care Manager, or PCP
- Develops and maintains collaborative relationships with community- based organizations in the LMH-ACO Service Area
- Follows-up with members within three days of inpatient hospital discharge or Emergency Department visit notification
- Helps to contribute to implementation of member`s Care Plan, as directed
- Provides input to member?s LMH-ACO Social Worker and/or RN Care Manager in developing and, when needed, updating and revising member?s Care Pan
- Under the direction of the LMH-ACO Social Worker (or RN Care Manager as appropriate), assists in the formation and operation of a Care Team for each engaged member
- Coordinates logistics to support member?s Care Plan adherence, such as appointment reminders, transportation, and childcare arrangements, as needed
- Organizes and communicates member?s treatment schedule, as applicable
- Helps to identify and address member medication adherence issues by ongoing timely reporting of member medication-related issues and concerns to the member?s RN Care Manager and/or Social Worker
- Supports and assists member to address and achieve their Care Plan goals.
- Assists member to identify and address barriers to compliance with their Care Plan and/or achievement of their Care Plan goals.
- Provides Emergency Department visit support, as directed
- Addresses member?s level of functioning and symptoms following guided script and reports status updates to member?s Social Worker or RN Care Manager
- Facilitates member?s timely access to their PCP or other providers, as directed by member?s LMH-ACO Social Worker and/or RN Care Manager
- Supports safe transitions of care for members moving between care settings


Minimum Qualifications

Education: High School Diploma or General Education Diploma (GED) required. Associate's degree or Bachelor's degree in psychology, social work or related human services field from an accredited college or university a plus

1 year experience in community-based social services or behavioral health support program required; 2-3 years' experience preferred. Candidate may be a licensed clinician who does not have the credentials to practice independently (e.g., LPN, LSW, or degree in a related health care field)

Skills, Knowledge & Abilities:
- Must have basic knowledge of medical/health care delivery environment and medical terminology
- Working knowledge of health plans and benefits a plus
- Demonstrated ability to work collaboratively within a multi-disciplinary team
- Demonstrated strong communication skills (both written and verbal)
- Self-directed with demonstrated strong time management and organizational skills
- Must demonstrate appropriate boundaries regarding confidentiality and personal relationships
- Strong ability to evaluate what is needed by each individual and adjust approach accordingly, using a strength-based, member-centered approach to care planning
- Strong problem - solving ability and critical thinking skills
- Experience with local community resources and navigating
mental health and/or substance use disorder treatment systems preferred
- Ability to utilize computers, web-based applications, and MS Office application required

Other Job Requirements:

Schedule Requirements: Some flexible work hours to accomplish member outreach and engagement at times when members are reachable; this may involve some early evening hours or later work days.

Travel Requirements: Must have a current, valid driver's license and own transportation. Travel and an ability to meet with members served in a variety of outreach settings is required.



About Lahey Health

The Lahey Model of Care - right care, right time, right place - is exactly what patients, providers and payers need and deserve. Identifying and delivering on this convergence of interests has positioned Lahey Health for further growth. Our model ensures care is highly coordinated and locally delivered, with lower costs and exceptional quality.

Lahey Health is a robust, regional system including a teaching hospital, community hospitals, primary care providers, specialists, behavioral and home health services, skilled nursing and rehabilitation facilities, and senior care resources throughout northeastern Massachusetts and southern New Hampshire. The system has a global presence with programs in Canada, Jordan and Bermuda.

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