Welcome to the Beth Israel Lahey Health Performance Network (BILHPN). BILHPN is a clinically integrated network of physicians, clinicians, and hospitals committed to providing high-quality, cost-effective care to the patients and communities they serve, while effectively managing medical expense. Leveraging best practices in population health management and data analytics, BILHPN improves care quality and patient health outcomes across Beth Israel Lahey Health through population health initiatives. BILHPN brings together the expertise of more than 4,500 providers across Eastern Massachusetts who share a common goal to achieve success in a value-based delivery system.
About the Job
BILHPN Masshealth-ACO is responsible for improving coordination of patient care, reducing unnecessary hospitalizations and readmissions, emergency department visits and revisits, and reducing the total cost of care over time. BILHPN Masshealth 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 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.
The Community Health Workers Responsibilities Are:
- 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 BILHPN Masshealth ACO Care Management Program
- Documents each outreach attempt in the BILHPN Masshealth 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 BILHPN Masshealth 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 114850 Page 2 of 6 Created: February 2018
- 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 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 members to access further treatment, self-help groups, housing, community based programs 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
- 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 ACO Service Area
- Helps to contribute to implementation of member‘s Care Plan, as directed
- Provides input to member’s BILHPN Masshealth ACO Social Worker and/or RN Care Manager in developing and, when needed, updating and revising member’s Care Pan
- Coordinates logistics to support member’s Care Plan adherence, such as appointment reminders, transportation, and childcare arrangements, as needed
- 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
- 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 BILHPN Masshealth ACO Social Worker and/or RN Care Manager
- Supports safe transitions of care for members moving between care settings
- This is a Masshealth waiver funded position
- 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)
Beth Israel Lahey Health is dedicated to improving health and wellness and making a difference in the lives of our patients, their families and all members of the communities we serve. Formed in March 2019, Beth Israel Lahey Health is a patient-centered, integrated care delivery system providing a continuum of services spanning academic, tertiary and community hospitals, dedicated orthopedic and psychiatric hospitals, primary and specialty care, community acute care, ambulatory care, behavioral services and home health. Beth Israel Lahey Health Performance Network is a unified joint contracting and population health management organization, jointly governed by participating physicians and hospitals.
Equal Opportunity Employer/Minorities/Females/Disabled/Veterans.